{"hospital_name":"MEMORIAL SATILLA HEALTH","last_updated_on":"2026-03-01","version":"3.0.0","location_name":["MEMORIAL SATILLA HEALTH"],"hospital_address":["1900 Tebeau St, Waycross, GA, 31501"],"license_information":{"license_number":"148-721","state":"GA"},"type_2_npi":["1922530468"],"attestation":{"attestation":"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","confirm_attestation":true,"attester_name":"Damon Barrett"},"standard_charge_information":[{"description":"Radiologic examination, knee; 1 or 2 views ","code_information":[{"code":"618","type":"RC"},{"code":"73560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"PTEN (Phosphatase and tensin monolog) full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions and variants in non-unique ","code_information":[{"code":"0235U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":600.000,"maximum":618.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":600.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":618.000,"methodology":"fee schedule"}]}]},{"description":"Acute gastrointestinal blood loss imaging ","code_information":[{"code":"614","type":"RC"},{"code":"78278","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Injection, elranatamab-bcmm, 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J1323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":311.060,"maximum":311.060,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":311.060,"methodology":"fee schedule"}]}]},{"description":"Plastic repair of salivary duct, sialodochoplasty; secondary or complicated ","code_information":[{"code":"42505","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws ","code_information":[{"code":"27506","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Valvectomy, tricuspid valve, with cardiopulmonary bypass ","code_information":[{"code":"33460","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; 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through separate incision ","code_information":[{"code":"367","type":"RC"},{"code":"50236","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hydroxyprogesterone, 17-d ","code_information":[{"code":"314","type":"RC"},{"code":"83498","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.170,"maximum":27.990,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.990,"methodology":"fee schedule"}]}]},{"description":"Unlisted ultrasound procedure (eg, diagnostic, interventional) ","code_information":[{"code":"351","type":"RC"},{"code":"76999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and repo ","code_information":[{"code":"349","type":"RC"},{"code":"75580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1047.910,"maximum":1047.910,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1047.910,"methodology":"fee schedule"}]}]},{"description":"Transurethral destruction of prostate tissue; by radiofrequency thermotherapy ","code_information":[{"code":"499","type":"RC"},{"code":"53852","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed ","code_information":[{"code":"616","type":"RC"},{"code":"77402","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":112.780,"maximum":112.780,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":112.780,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, open, extensor, foot or toe, each tendon ","code_information":[{"code":"28234","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (List separately in addition to code for primary procedure) ","code_information":[{"code":"0570T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Netupitant 300 mg and palonosetron 0.5 mg, oral ","code_information":[{"code":"J8655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":396.740,"maximum":1026.510,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":507.550,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":492.390,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1026.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":396.740,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1005.560,"methodology":"fee schedule"}]}]},{"description":"Repair of omphalocele (Gross type operation); second stage ","code_information":[{"code":"361","type":"RC"},{"code":"49611","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Protoporphyrin, RBC; quantitative ","code_information":[{"code":"314","type":"RC"},{"code":"84202","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.350,"maximum":14.780,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.780,"methodology":"fee schedule"}]}]},{"description":"Amino acids; multiple, qualitative, each specimen ","code_information":[{"code":"82128","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13.870,"maximum":16.640,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.870,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna ","code_information":[{"code":"25375","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Infectious disease (genitourinary pathogens), antibiotic-resistance gene detection, multiplex amplified probe technique, urine, reported as an antimicrobial stewardship risk score ","code_information":[{"code":"0372U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":500.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":500.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":500.140,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":429.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.780,"methodology":"fee schedule"}]}]},{"description":"Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition to code for primary procedure) ","code_information":[{"code":"33518","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA an ","code_information":[{"code":"311","type":"RC"},{"code":"81445","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":597.910,"maximum":615.850,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":597.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":615.850,"methodology":"fee schedule"}]}]},{"description":"Infusion or instillation of radioelement solution (includes 3-month follow-up care) ","code_information":[{"code":"321","type":"RC"},{"code":"77750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":270.870,"maximum":756.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":621.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":705.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":621.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":756.240,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":444.300,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":270.870,"methodology":"fee schedule"}]}]},{"description":"Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach ","code_information":[{"code":"0545T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Capsulotomy, midtarsal (eg, Heyman type procedure) ","code_information":[{"code":"28264","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach ","code_information":[{"code":"0545T","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10376.500,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) ","code_information":[{"code":"340","type":"RC"},{"code":"74181","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"Reduction of volvulus, intussusception, internal hernia, by laparotomy ","code_information":[{"code":"44050","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sympathectomy, lumbar ","code_information":[{"code":"490","type":"RC"},{"code":"64818","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Gingivectomy, excision gingiva, each quadrant ","code_information":[{"code":"41820","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, elastography; first target lesion ","code_information":[{"code":"341","type":"RC"},{"code":"76982","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmon ","code_information":[{"code":"32855","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Hemolysins and agglutinins; auto, screen, each ","code_information":[{"code":"309","type":"RC"},{"code":"86940","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.770,"maximum":10.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10.520,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.770,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.770,"methodology":"fee schedule"}]}]},{"description":"Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below ","code_information":[{"code":"37722","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"350","type":"RC"},{"code":"73706","type":"CPT"},{"code":"824649","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":401.740,"gross_charge":4432.50,"discounted_cash":4432.50,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"Excision aural glomus tumor; transmastoid ","code_information":[{"code":"69552","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Oncology (pan tumor) whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses ","code_information":[{"code":"0298U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2919.600,"maximum":3007.190,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2919.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3007.190,"methodology":"fee schedule"}]}]},{"description":"Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands ","code_information":[{"code":"42509","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) ","code_information":[{"code":"43264","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rhinectomy; partial ","code_information":[{"code":"30150","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":9398.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":9398.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":9398.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":6713.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Burr hole(s); with aspiration of hematoma or cyst, intracerebral ","code_information":[{"code":"61156","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia ","code_information":[{"code":"361","type":"RC"},{"code":"46045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tonsillectomy and adenoidectomy; age 12 or over ","code_information":[{"code":"367","type":"RC"},{"code":"42821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagectomy, total or near total, with laparoscopic mobilization of the abdominal and mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with ","code_information":[{"code":"362","type":"RC"},{"code":"43286","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"156","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":837.360,"maximum":929.470,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":887.600,"methodology":"fee schedule","additional_payer_notes":"Days 5. 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duplication/deletion variant(s) ","code_information":[{"code":"305","type":"RC"},{"code":"81363","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":202.400,"maximum":242.880,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":206.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":242.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":206.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":242.880,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":202.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":208.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":202.400,"methodology":"fee schedule"}]}]},{"description":"CEBPA (CCAAT/enhancer binding protein ºC/EBP», alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence ","code_information":[{"code":"312","type":"RC"},{"code":"81218","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":241.900,"maximum":249.160,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":241.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":249.160,"methodology":"fee schedule"}]}]},{"description":"Incision of conjunctiva, drainage of cyst ","code_information":[{"code":"362","type":"RC"},{"code":"68020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedu ","code_information":[{"code":"367","type":"RC"},{"code":"44360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation ","code_information":[{"code":"24620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4098.580,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4098.580,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4014.930,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"320","type":"RC"},{"code":"72194","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":313.570,"maximum":381.310,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":313.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":355.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":313.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":381.310,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of thigh or knee area; superficial ","code_information":[{"code":"27323","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) Neck/Spine","code_information":[{"code":"22842","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13504.100,"maximum":16426.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15318.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16426.200,"methodology":"case rate"}]}]},{"description":"Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"49452","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, phalanges of foot ","code_information":[{"code":"28108","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Cyanocobalamin (Vitamin B-12); 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other than vertical-banded gastroplasty ","code_information":[{"code":"43843","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10560.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"New Technology - Level 18 ","code_information":[{"code":"01555","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1534.990,"maximum":1534.990,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":1534.990,"methodology":"fee schedule"}]}]},{"description":"Injection, calcium gluconate (wg critical care), not therapeutically equivalent to j0612, 10 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J0613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.150,"maximum":0.150,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.150,"methodology":"fee schedule"}]}]},{"description":"Therapeutic apheresis; 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excised diameter 2.1 to 3.0 cm ","code_information":[{"code":"11643","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venograp ","code_information":[{"code":"0795T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":26334.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm ","code_information":[{"code":"17272","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Aortography, abdominal, by serialography, radiological supervision and interpretation ","code_information":[{"code":"403","type":"RC"},{"code":"75625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3241.930,"maximum":3241.930,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3241.930,"methodology":"fee schedule"}]}]},{"description":"Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element ","code_information":[{"code":"0238U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":584.900,"maximum":602.450,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":584.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":602.450,"methodology":"fee schedule"}]}]},{"description":"Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure ","code_information":[{"code":"305","type":"RC"},{"code":"88344","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":291.260,"maximum":349.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":349.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":349.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.260,"methodology":"fee schedule"}]}]},{"description":"Oncology (lung), plasma analysis of 388 proteins, using aptamer-based proteomics technology, predictive algorithm reported as clinical benefit from immune checkpoint inhibitor therapy ","code_information":[{"code":"0436U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1504.240,"maximum":1805.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1534.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1805.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1534.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1805.090,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1504.240,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1549.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1504.240,"methodology":"fee schedule"}]}]},{"description":"Xwrap dual plus, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Cholecystoenterostomy; Roux-en-Y ","code_information":[{"code":"369","type":"RC"},{"code":"47740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Closure of esophagostomy or fistula; cervical approach ","code_information":[{"code":"43420","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic root remodeling (eg, David Procedure, Yacoub Procedure) ","code_information":[{"code":"33864","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) ","code_information":[{"code":"23472","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Immunoassay for tumor antigen, qualitative or semiquantitative (eg, bladder tumor antigen) ","code_information":[{"code":"314","type":"RC"},{"code":"86294","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.570,"maximum":26.340,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":26.340,"methodology":"fee schedule"}]}]},{"description":"Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress ","code_information":[{"code":"E0295","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":105.060,"maximum":113.730,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":109.390,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":111.560,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":113.730,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":108.310,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":113.730,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":113.730,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":109.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":109.390,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":109.390,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":108.310,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":105.060,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":108.310,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":113.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":110.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":108.310,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":108.310,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":110.480,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy ","code_information":[{"code":"27286","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Biopsy or excision of lymph node(s); open, internal mammary node(s) ","code_information":[{"code":"360","type":"RC"},{"code":"38530","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal ","code_information":[{"code":"67005","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted immune globulin ","code_information":[{"code":"892","type":"RC"},{"code":"90399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":706.020,"maximum":706.020,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":706.020,"methodology":"fee schedule"}]}]},{"description":"Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft ","code_information":[{"code":"21143","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective filtration and plasma reinfusion ","code_information":[{"code":"36516","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of foreign body in scrotum ","code_information":[{"code":"55120","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial ","code_information":[{"code":"29895","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"44384","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4353.590,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4353.590,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4264.740,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"126","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1080.420,"maximum":1199.270,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1145.250,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1080.420,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1080.420,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1199.270,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1199.270,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap ","code_information":[{"code":"19367","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Voriconazole ","code_information":[{"code":"300","type":"RC"},{"code":"80285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.110,"maximum":32.530,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":27.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":27.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32.530,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27.110,"methodology":"fee schedule"}]}]},{"description":"Tenolysis, flexor, foot; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Incision and drainage, upper arm or elbow area; bursa ","code_information":[{"code":"23931","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4005.850,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4005.850,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":3924.100,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Non-randomized, non-blinded procedure for nyha class ii, iii, iv heart failure; transcatheter implantation of interatrial shunt, including right and left heart catheterization, transeptal puncture, tr ","code_information":[{"code":"490","type":"RC"},{"code":"C9760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":10376.500,"maximum":33480.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33480.000,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC  IPF","code_information":[{"code":"156","type":"RC"},{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":959.250,"maximum":1064.770,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1016.810,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":959.250,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":959.250,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1064.770,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1064.770,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"116","type":"RC"},{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"96361","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":78.940,"maximum":78.940,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":78.940,"methodology":"fee schedule"}]}]},{"description":"Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) ","code_information":[{"code":"0413T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands ","code_information":[{"code":"0490T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7234.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, cervical spine; without contrast material ","code_information":[{"code":"351","type":"RC"},{"code":"72125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":245.180,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus) ","code_information":[{"code":"87632","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":218.060,"maximum":261.670,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":222.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":261.670,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":222.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":261.670,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":224.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":218.060,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary ","code_information":[{"code":"37258","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological s ","code_information":[{"code":"50694","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8162.410,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8162.410,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7995.830,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level ","code_information":[{"code":"0216T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7234.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, ","code_information":[{"code":"367","type":"RC"},{"code":"37243","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":9657.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC Pediatric","code_information":[{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8959.130,"maximum":12542.440,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":12542.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":12542.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":12542.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":12542.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":8959.130,"methodology":"fee schedule"}]}]},{"description":"Craniectomy for excision of brain tumor, infratentorial or posterior fossa; midline tumor at base of skull ","code_information":[{"code":"61521","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach ","code_information":[{"code":"21296","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty ","code_information":[{"code":"24587","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Carpectomy; all bones of proximal row ","code_information":[{"code":"25215","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CORRECTION OF BUNION ","code_information":[{"code":"28294","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7549.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy ","code_information":[{"code":"48153","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroscopy, shoulder, surgical; repair of SLAP lesion ","code_information":[{"code":"29807","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Introduction of catheter, right heart or main pulmonary artery ","code_information":[{"code":"36013","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency) ","code_information":[{"code":"369","type":"RC"},{"code":"46930","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Exploration of spinal fusion ","code_information":[{"code":"22830","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, wrist; 2 views ","code_information":[{"code":"321","type":"RC"},{"code":"73100","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":41.930,"maximum":50.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":41.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":47.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":41.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.980,"methodology":"fee schedule"}]}]},{"description":"Fetal aneuploidy DNA sequencing comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism and segmental ","code_information":[{"code":"0341U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1900.200,"maximum":2280.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1938.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2280.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1938.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2280.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1900.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1957.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1900.200,"methodology":"fee schedule"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC ","code_information":[{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11973.000,"maximum":31986.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":29344.590,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":12571.990,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":29344.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":29344.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":29344.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":20960.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":26296.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":29829.960,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":12820.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":26296.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31986.330,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":15559.390,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":12696.460,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":12696.460,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14818.190,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":12945.410,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15964.000,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":12945.410,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":11973.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12571.990,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":12571.990,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":12571.990,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":12447.510,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":12945.410,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":14515.780,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":12945.410,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13069.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12186.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":12447.510,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":12447.510,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":12696.460,"methodology":"fee schedule"}]}]},{"description":"Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to codeºs» for other technical and ","code_information":[{"code":"305","type":"RC"},{"code":"88155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.650,"maximum":15.090,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.650,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.090,"methodology":"fee schedule"}]}]},{"description":"Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart ca ","code_information":[{"code":"360","type":"RC"},{"code":"C7553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time ","code_information":[{"code":"409","type":"RC"},{"code":"76000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":69.820,"maximum":517.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":69.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":79.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":69.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":84.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg ","code_information":[{"code":"J7320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":6.120,"maximum":15.840,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":7.110,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":7.240,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":15.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":6.120,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":15.510,"methodology":"fee schedule"}]}]},{"description":"Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75743","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":115.110,"maximum":139.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":115.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":130.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":115.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":139.980,"methodology":"fee schedule"}]}]},{"description":"Drainage of perineal urinary extravasation; uncomplicated (separate procedure) ","code_information":[{"code":"53080","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1674.810,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1709.700,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1674.810,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra ","code_information":[{"code":"53415","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tacrolimus ","code_information":[{"code":"303","type":"RC"},{"code":"80197","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.730,"maximum":16.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.480,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.730,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty with prosthetic replacement; lunate ","code_information":[{"code":"25444","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Suture, secondary, of abdominal wall for evisceration or dehiscence ","code_information":[{"code":"49900","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Perfluroalkyl substances, 16 PFAS compounds by liquid chromatography with tandem mass spectrometry, plasma or serum, quantitative ","code_information":[{"code":"0394U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":198.740,"maximum":238.490,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":202.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":238.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":202.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":238.490,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":198.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":204.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":198.740,"methodology":"fee schedule"}]}]},{"description":"Injection, eptifibatide, 5 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J1327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.810,"maximum":5.810,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.810,"methodology":"fee schedule"}]}]},{"description":"REPLACEMENT OF LOWER EXT JOINT; M > 28.65 & M < 37 ","code_information":[{"code":"138","type":"RC"},{"code":"B0804","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":27041.550,"maximum":30016.120,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":28664.040,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":27041.550,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":30016.120,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":28393.630,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27311.970,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":27311.970,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":27311.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":27041.550,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":30016.120,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":30016.120,"methodology":"fee schedule"}]}]},{"description":"Excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic ","code_information":[{"code":"47712","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revision of stapedectomy or stapedotomy ","code_information":[{"code":"481","type":"RC"},{"code":"69662","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Infectious disease (genitourinary pathogens), antibiotic-resistance gene detection, multiplex amplified probe technique, urine, reported as an antimicrobial stewardship risk score ","code_information":[{"code":"0372U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":429.280,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":429.280,"methodology":"fee schedule"}]}]},{"description":"Fistulization of sclera for glaucoma; trephination with iridectomy ","code_information":[{"code":"481","type":"RC"},{"code":"66150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Reduction of craniomegalic skull (eg, treated hydrocephalus); 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each additional branch of a major coronary artery (list separately in addition to ","code_information":[{"code":"369","type":"RC"},{"code":"C9601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":26130.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13515.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15332.300,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13515.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16440.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26130.000,"methodology":"case rate"}]}]},{"description":"Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0270U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":608.170,"maximum":729.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":620.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":729.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":620.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":729.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":626.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":608.170,"methodology":"fee schedule"}]}]},{"description":"Detachable, non-adjustable height armrest, replacement only, each ","code_information":[{"code":"K0015","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":20.050,"maximum":21.700,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":20.880,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":21.290,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21.700,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20.670,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21.700,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":21.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20.880,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20.880,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20.880,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":20.670,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":20.670,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":20.670,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":20.670,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":21.080,"methodology":"fee schedule"}]}]},{"description":"Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx ","code_information":[{"code":"42815","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure ","code_information":[{"code":"367","type":"RC"},{"code":"52442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor; scapula ","code_information":[{"code":"23210","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thiamine (Vitamin B-1) ","code_information":[{"code":"303","type":"RC"},{"code":"84425","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.230,"maximum":25.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":25.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25.480,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.230,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.230,"methodology":"fee schedule"}]}]},{"description":"Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure) ","code_information":[{"code":"15777","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ileoscopy, through stoma; with transendoscopic balloon dilation ","code_information":[{"code":"44381","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, ","code_information":[{"code":"32998","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Thrombolysis, coronary; by intravenous infusion ","code_information":[{"code":"480","type":"RC"},{"code":"92977","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5947.170,"maximum":7234.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps ","code_information":[{"code":"43250","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, conjunctiva ","code_information":[{"code":"490","type":"RC"},{"code":"68399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, penicillin g benzathine, 100,000 units ","code_information":[{"code":"344","type":"RC"},{"code":"J0561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":52.750,"maximum":52.750,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":52.750,"methodology":"fee schedule"}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy ","code_information":[{"code":"361","type":"RC"},{"code":"50555","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; popliteal artery ","code_information":[{"code":"35303","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material ","code_information":[{"code":"610","type":"RC"},{"code":"74176","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"Oncology (breast), augmentative algorithmic analysis of digitized whole slide imaging of 8 histologic and immunohistochemical features, reported as a recurrence score ","code_information":[{"code":"0418U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":706.250,"maximum":847.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":720.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":847.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":720.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":847.500,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":706.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":727.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":706.250,"methodology":"fee schedule"}]}]},{"description":"Cardiac shunt detection ","code_information":[{"code":"359","type":"RC"},{"code":"78428","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Antibody; Borrelia (relapsing fever) ","code_information":[{"code":"312","type":"RC"},{"code":"86619","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.380,"maximum":13.780,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.780,"methodology":"fee schedule"}]}]},{"description":"Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells, from culturedCSCs and primary tumor cells, categorical drug response reported based on cytotoxicity percentage observed, minimu ","code_information":[{"code":"0435U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3033.860,"maximum":3640.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3094.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3640.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3094.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3640.630,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3033.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3124.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3033.860,"methodology":"fee schedule"}]}]},{"description":"Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations ","code_information":[{"code":"44603","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis ","code_information":[{"code":"329","type":"RC"},{"code":"75898","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":268.810,"maximum":326.880,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":268.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":304.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":268.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":326.880,"methodology":"fee schedule"}]}]},{"description":"Transfer iliopsoas; to femoral neck ","code_information":[{"code":"27111","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"MSH6 (mutS homolog 6 ºE. coli») (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis ","code_information":[{"code":"306","type":"RC"},{"code":"81298","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":641.850,"maximum":770.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":654.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":770.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":654.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":770.220,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":641.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":661.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":641.850,"methodology":"fee schedule"}]}]},{"description":"Duograft aa, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"Q4376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"STROKE; M > 30.05 & M < 34.25 ","code_information":[{"code":"138","type":"RC"},{"code":"B0106","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":45624.970,"maximum":50643.710,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":48362.460,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":45624.970,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":50643.710,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":47906.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":46081.220,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":46081.220,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":46081.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":45624.970,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":50643.710,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":50643.710,"methodology":"fee schedule"}]}]},{"description":"Excision of chest wall tumor involving rib(s), with plastic reconstruction; without mediastinal lymphadenectomy ","code_information":[{"code":"21602","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) ","code_information":[{"code":"351","type":"RC"},{"code":"73219","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":367.840,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"}]}]},{"description":"Excision of neuroma; hand or foot, each additional nerve, except same digit (List separately in addition to code for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"64783","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Esano a, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Ureterotomy with exploration or drainage (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"50600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Lymphangiography, extremity only, bilateral, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75803","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":83.350,"maximum":101.360,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":83.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":94.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":83.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":101.360,"methodology":"fee schedule"}]}]},{"description":"Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time ","code_information":[{"code":"95800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":21.58,"standard_charge_algorithm":"Reimbursement will be 21.58% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imagi ","code_information":[{"code":"499","type":"RC"},{"code":"92978","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":9657.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Acetylcholine receptor (AChR); modulating antibody ","code_information":[{"code":"304","type":"RC"},{"code":"86043","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.050,"maximum":14.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.460,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.050,"methodology":"fee schedule"}]}]},{"description":"Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and distinct session from insertion ","code_information":[{"code":"33997","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC ","code_information":[{"code":"605","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7144.800,"maximum":19087.610,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":17511.170,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":8203.930,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":17511.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":17511.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":17511.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":12507.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15692.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17800.810,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":8366.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15692.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19087.610,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":10153.380,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":8285.160,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":8285.160,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8916.390,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":8447.610,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9526.400,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":8447.610,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":7144.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":8203.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":8203.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":8203.930,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":8122.700,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":8447.610,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11221.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8734.430,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":8447.610,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8528.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10550.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7952.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":8122.700,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":8122.700,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":8285.160,"methodology":"fee schedule"}]}]},{"description":"Unlisted endocrine procedure, diagnostic nuclear medicine ","code_information":[{"code":"341","type":"RC"},{"code":"78099","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":848.520,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":848.520,"methodology":"fee schedule"}]}]},{"description":"Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), ","code_information":[{"code":"47535","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Calcitonin stimulation panel (eg, calcium, pentagastrin) This panel must include the following: Calcitonin (82308 x 3) ","code_information":[{"code":"80410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":68.820,"maximum":96.440,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":72.330,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":81.170,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":72.330,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":72.330,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":72.330,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":72.330,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":84.390,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":82.780,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":81.980,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":84.390,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":80.370,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":84.390,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":84.390,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":96.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":81.170,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":81.170,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":81.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":80.370,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":68.820,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":80.370,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":84.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":81.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":80.370,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":80.370,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":81.980,"methodology":"fee schedule"}]}]},{"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 up to 100 sq cm; each additional 25 sq ","code_information":[{"code":"15276","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) ","code_information":[{"code":"306","type":"RC"},{"code":"86300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.810,"maximum":24.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.970,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.810,"methodology":"fee schedule"}]}]},{"description":"Salivary gland function study ","code_information":[{"code":"359","type":"RC"},{"code":"78232","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Antibody; Shigella ","code_information":[{"code":"310","type":"RC"},{"code":"86771","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.480,"maximum":25.210,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":24.480,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":25.210,"methodology":"fee schedule"}]}]},{"description":"Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral ","code_information":[{"code":"0971T","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6271.280,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"}]}]},{"description":"Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) ","code_information":[{"code":"55842","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC ","code_information":[{"code":"086","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5860.080,"maximum":6343.390,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":6343.390,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":5860.080,"methodology":"fee schedule"}]}]},{"description":"TRANSCERVICAL UTERINE FIBROID(S) ABLATION WITH ULTRASOUND GUIDANCE, RADIOFREQUENCY ","code_information":[{"code":"0404T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Antibody; Haemophilus influenza ","code_information":[{"code":"86684","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":15.840,"maximum":19.010,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.010,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.840,"methodology":"fee schedule"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space ","code_information":[{"code":"41007","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Renal vein renin stimulation panel (eg, captopril) This panel must include the following: Renin (84244 x 6) ","code_information":[{"code":"312","type":"RC"},{"code":"80416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":209.320,"maximum":215.600,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":209.320,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":215.600,"methodology":"fee schedule"}]}]},{"description":"Liver and spleen imaging; with vascular flow ","code_information":[{"code":"329","type":"RC"},{"code":"78216","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; double-contrast (eg, high-density barium and air via enteroclysis tube) stu ","code_information":[{"code":"359","type":"RC"},{"code":"74251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Vitamin A ","code_information":[{"code":"84590","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11.610,"maximum":13.930,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.610,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1120.810,"maximum":1244.100,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1120.810,"methodology":"fee schedule","additional_payer_notes":"Days 4. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, soft tissue neck; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"70490","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":145.990,"maximum":177.530,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":145.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":165.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":145.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":177.530,"methodology":"fee schedule"}]}]},{"description":"Repair medial collateral ligament, elbow, with local tissue ","code_information":[{"code":"24345","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of r ","code_information":[{"code":"51597","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagoscopy, flexible, transoral; with band ligation of esophageal varices ","code_information":[{"code":"43205","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Fibrin(ogen) degradation (split) products (FDP) (FSP); paracoagulation ","code_information":[{"code":"310","type":"RC"},{"code":"85366","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":80.460,"maximum":82.870,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":80.460,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":82.870,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) ","code_information":[{"code":"480","type":"RC"},{"code":"58661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or m ","code_information":[{"code":"367","type":"RC"},{"code":"49411","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Plastic repair of introitus ","code_information":[{"code":"56800","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":38190.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":38190.000,"methodology":"case rate"}]}]},{"description":"CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) ","code_information":[{"code":"307","type":"RC"},{"code":"81227","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.810,"maximum":209.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":178.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":209.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":178.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":209.770,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":174.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":180.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":174.810,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) ","code_information":[{"code":"402","type":"RC"},{"code":"70540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"NONTRAUMATIC BRAIN INJURY; M > 35.05 & M < 41.05 ","code_information":[{"code":"158","type":"RC"},{"code":"A0302","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":17207.820,"maximum":19100.680,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":18240.290,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":17207.820,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":19100.680,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":18068.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17379.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":17379.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":17379.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":17207.820,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":19100.680,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":19100.680,"methodology":"fee schedule"}]}]},{"description":"Medial canthopexy (separate procedure) ","code_information":[{"code":"21280","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"O.R. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Correction of trichiasis; epilation, by forceps only ","code_information":[{"code":"367","type":"RC"},{"code":"67820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure) ","code_information":[{"code":"61783","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Implantation or replacement of gastric neurostimulator electrodes, antrum, open ","code_information":[{"code":"367","type":"RC"},{"code":"43881","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar ","code_information":[{"code":"22207","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Lower extremity fascial plane block, unilateral; by injection(s), including imaging guidance, when performed ","code_information":[{"code":"361","type":"RC"},{"code":"64473","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus ºbowleg» or genu valgus ºknock-knee»); after epiphyseal closure ","code_information":[{"code":"27457","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency ","code_information":[{"code":"47382","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thyroid imaging (including vascular flow, when performed); ","code_information":[{"code":"78013","type":"CPT"},{"code":"818465","type":"CDM"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1010.490,"maximum":1031.540,"gross_charge":2052.00,"discounted_cash":2052.00,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1031.540,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1010.490,"methodology":"fee schedule"}]}]},{"description":"Copper ","code_information":[{"code":"314","type":"RC"},{"code":"82525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.410,"maximum":12.780,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.780,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) ","code_information":[{"code":"324","type":"RC"},{"code":"74713","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":179.960,"maximum":218.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":179.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":204.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":179.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":218.840,"methodology":"fee schedule"}]}]},{"description":"Unlisted hysteroscopy procedure, uterus ","code_information":[{"code":"490","type":"RC"},{"code":"58579","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Repair of low imperforate anus; with anoperineal fistula (cut-back procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"46715","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (lung), plasma analysis of 388 proteins, using aptamer-based proteomics technology, predictive algorithm reported as clinical benefit from immune checkpoint inhibitor therapy ","code_information":[{"code":"0436U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1504.240,"maximum":1805.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1534.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1805.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1534.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1805.090,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1504.240,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1549.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1504.240,"methodology":"fee schedule"}]}]},{"description":"Post-coital direct, qualitative examinations of vaginal or cervical mucous ","code_information":[{"code":"Q0115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":15.780,"maximum":30.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":22.500,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":25.250,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":22.500,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":22.500,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":22.500,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":22.500,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":16.240,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":25.750,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":15.780,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":26.250,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":25.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":26.250,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":26.250,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":25.250,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":25.250,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":25.250,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":25.000,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":21.410,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":25.000,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":26.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":25.000,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":25.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":25.500,"methodology":"fee schedule"}]}]},{"description":"Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy ","code_information":[{"code":"59121","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation ","code_information":[{"code":"23450","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of nasal septal fracture, with or without stabilization ","code_information":[{"code":"21337","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Exploration for postoperative hemorrhage, thrombosis or infection; abdomen ","code_information":[{"code":"35840","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Capsulodesis, metacarpophalangeal joint; 2 digits ","code_information":[{"code":"26517","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Rare DS Whl Gen & Mitochdrl DNA Seq Alys Ea Cmprtr ","code_information":[{"code":"0213U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2709.950,"maximum":3251.940,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2764.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3251.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2764.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3251.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2709.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2791.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2709.950,"methodology":"fee schedule"}]}]},{"description":"OTHER FACTORS INFLUENCING HEALTH STATUS One Day Stay","code_information":[{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC ","code_information":[{"code":"209","type":"RC"},{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10391.800,"maximum":12640.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11788.400,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12640.500,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia ","code_information":[{"code":"26775","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure) ","code_information":[{"code":"0136U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":407.430,"maximum":488.920,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":415.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":488.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":415.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":488.920,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":407.430,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":419.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":407.430,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast inje ","code_information":[{"code":"36251","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0DV64DZ","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3216.000,"maximum":3216.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3216.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC ","code_information":[{"code":"735","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10494.900,"maximum":28037.530,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":25721.920,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":11234.760,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":25721.920,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":25721.920,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":25721.920,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":18372.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":23049.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":26147.370,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":11457.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":23049.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28037.530,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":13904.400,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":11345.990,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":11345.990,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":11717.670,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":11568.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13993.200,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":11568.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":10494.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11234.760,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":11234.760,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":11234.760,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":11123.520,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":11568.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":11478.540,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":11568.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11679.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10889.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":11123.520,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11123.520,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":11345.990,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, talus or calcaneus; ","code_information":[{"code":"28100","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm ","code_information":[{"code":"11644","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without ","code_information":[{"code":"499","type":"RC"},{"code":"50957","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Vestibuloplasty; posterior, unilateral ","code_information":[{"code":"40842","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 ","code_information":[{"code":"0027U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":121.910,"maximum":146.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":124.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":146.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":124.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":146.290,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":121.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":121.910,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion ","code_information":[{"code":"29886","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Release of extensive scar tissue without detaching extraocular muscle (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"67343","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, maxillofacial area; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"70487","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":292.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":240.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":272.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":240.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":292.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Proctectomy; partial resection of rectum, transabdominal approach ","code_information":[{"code":"45111","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; double-contrast (eg, high-density barium and air via enteroclysis tube) stu ","code_information":[{"code":"611","type":"RC"},{"code":"74251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Luteinizing releasing factor (LRH) ","code_information":[{"code":"306","type":"RC"},{"code":"83727","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.190,"maximum":20.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.630,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.190,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.190,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, nerve(s) and accompanying structures throughout their entire anatomic course in one extremity, comprehensive, including real-time cine imaging with image documentation, per extremity ","code_information":[{"code":"616","type":"RC"},{"code":"76883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"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":"0798T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Insertion of tunneled intraperitoneal catheter for dialysis, open ","code_information":[{"code":"49421","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair blood vessel with vein graft; intrathoracic, with bypass ","code_information":[{"code":"35241","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Autologous muscle cell therapy, harvesting of muscle progenitor cells, including ultrasound guidance, when performed ","code_information":[{"code":"0999T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance a ","code_information":[{"code":"0707T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture) ","code_information":[{"code":"66682","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Oncology evaluation of 17 DNA biomarkers using droplet digital PCR, cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence ","code_information":[{"code":"0356U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1800.000,"maximum":2160.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2160.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1836.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2160.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1800.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1854.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1800.000,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) ","code_information":[{"code":"27006","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, transvaginal ","code_information":[{"code":"350","type":"RC"},{"code":"76830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine; thoracic, 2 views ","code_information":[{"code":"615","type":"RC"},{"code":"72070","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, sinuses, paranasal, complete, minimum of 3 views ","code_information":[{"code":"619","type":"RC"},{"code":"70220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of posterior malleolus fracture; with manipulation ","code_information":[{"code":"27768","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Impression and custom preparation; mandibular resection prosthesis ","code_information":[{"code":"21081","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization ","code_information":[{"code":"65450","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Aspiration and/or injection, thyroid cyst ","code_information":[{"code":"490","type":"RC"},{"code":"60300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children ","code_information":[{"code":"15110","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed ","code_information":[{"code":"39401","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) ","code_information":[{"code":"340","type":"RC"},{"code":"78016","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":49.510,"maximum":57.070,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":49.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":49.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":57.070,"methodology":"fee schedule"}]}]},{"description":"Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection ","code_information":[{"code":"38555","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Aluminum ","code_information":[{"code":"311","type":"RC"},{"code":"82108","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.480,"maximum":26.240,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.480,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":26.240,"methodology":"fee schedule"}]}]},{"description":"Destruction by neurolytic agent; pudendal nerve ","code_information":[{"code":"499","type":"RC"},{"code":"64630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Biopsy of penis; (separate procedure) ","code_information":[{"code":"54100","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantificat ","code_information":[{"code":"351","type":"RC"},{"code":"78451","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1344.640,"maximum":1344.640,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1344.640,"methodology":"fee schedule"}]}]},{"description":"Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (ie, McKeown esophagectomy or tri-incisional esophagectomy) ","code_information":[{"code":"43112","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Amputation, arm through humerus; with implant ","code_information":[{"code":"24931","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other pro ","code_information":[{"code":"49595","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RHEUMATOID, OTHER ARTHRITIS; M > 26.15 & M < 36.35 ","code_information":[{"code":"148","type":"RC"},{"code":"B1302","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":24741.380,"maximum":27462.930,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":26225.860,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":24741.380,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":27462.930,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":25978.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":24988.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":24988.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":24988.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":24741.380,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":27462.930,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":27462.930,"methodology":"fee schedule"}]}]},{"description":"Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve rootºs», ºeg, spinal or lateral recess stenosis»), single vertebral segm ","code_information":[{"code":"369","type":"RC"},{"code":"63045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation ","code_information":[{"code":"21432","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh ","code_information":[{"code":"351","type":"RC"},{"code":"78815","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1502.350,"maximum":1502.350,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1502.350,"methodology":"fee schedule"}]}]},{"description":"HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-A, -B, -C, -DRB1/3/4/5, and -DQB1 ","code_information":[{"code":"301","type":"RC"},{"code":"81370","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":402.120,"maximum":482.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":410.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":482.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":410.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":482.540,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":402.120,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":414.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":402.120,"methodology":"fee schedule"}]}]},{"description":"APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR (EG, TENS UNIT) ","code_information":[{"code":"64550","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing ","code_information":[{"code":"322","type":"RC"},{"code":"78494","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":235.840,"maximum":413.880,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":235.840,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"DEPRESSIVE NEUROSES  IPF","code_information":[{"code":"204","type":"RC"},{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":965.200,"maximum":965.200,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":965.200,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":965.200,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":965.200,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Repair blood vessel with graft other than vein; intrathoracic, with bypass ","code_information":[{"code":"35271","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Correction of lid retraction ","code_information":[{"code":"362","type":"RC"},{"code":"67911","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, foot; complete, minimum of 3 views ","code_information":[{"code":"400","type":"RC"},{"code":"73630","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":41.930,"maximum":50.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":41.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":47.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":41.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.980,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) ","code_information":[{"code":"27006","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"IMPLANTATION OF PATIENT-ACTIVATED CARDIAC EVENT RECORDER ","code_information":[{"code":"33282","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":10520.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve ","code_information":[{"code":"0440T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, metacarpophalangeal joint, with or without internal fixation; ","code_information":[{"code":"26850","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection, ceftazidime and avibactam, 0.5 g/0.125 g 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logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation of common iliac vein ","code_information":[{"code":"37660","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case 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","code_information":[{"code":"0440U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":854.000,"maximum":896.700,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":862.540,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":879.620,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":896.700,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":854.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":896.700,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":896.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":862.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":862.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":862.540,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":854.000,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":854.000,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":896.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":871.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":854.000,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":854.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":871.080,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed) ","code_information":[{"code":"361","type":"RC"},{"code":"43213","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH MCC One Day Stay","code_information":[{"code":"031","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal ","code_information":[{"code":"28306","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed; ","code_information":[{"code":"55866","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Anastomosis; facial-hypoglossal ","code_information":[{"code":"362","type":"RC"},{"code":"64868","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Safety enclosure frame/canopy for use with hospital bed, any type ","code_information":[{"code":"E0316","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":251.730,"maximum":272.500,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":262.120,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":267.310,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":272.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":259.520,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":272.500,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":272.500,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":262.120,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":262.120,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":262.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":259.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":251.730,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":259.520,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":272.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":264.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":259.520,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":259.520,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":264.710,"methodology":"fee schedule"}]}]},{"description":"Removal of tumor, temporal bone ","code_information":[{"code":"367","type":"RC"},{"code":"69970","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Kidney imaging morphology; with vascular flow ","code_information":[{"code":"614","type":"RC"},{"code":"78701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur ","code_information":[{"code":"27187","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hysteroplasty, repair of uterine anomaly (Strassman type) ","code_information":[{"code":"367","type":"RC"},{"code":"58540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) ","code_information":[{"code":"30580","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal ","code_information":[{"code":"67005","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) ","code_information":[{"code":"81224","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":144.500,"maximum":202.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":151.880,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":170.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":151.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":151.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":151.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":151.880,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":177.190,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":173.810,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":172.130,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":177.190,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":168.750,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":177.190,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":177.190,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":202.500,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":170.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":170.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":170.440,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":168.750,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":144.500,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":168.750,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":177.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":172.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":168.750,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":168.750,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":172.130,"methodology":"fee schedule"}]}]},{"description":"Excision or fulguration; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 3+. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":14418.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":10298.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":23762.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5989.000,"methodology":"case rate"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence ","code_information":[{"code":"309","type":"RC"},{"code":"81236","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":282.880,"maximum":339.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":288.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":339.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":288.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":339.460,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":291.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":282.880,"methodology":"fee schedule"}]}]},{"description":"Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood) ","code_information":[{"code":"26952","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiologi ","code_information":[{"code":"369","type":"RC"},{"code":"50432","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Closure of nephrocutaneous or pyelocutaneous fistula ","code_information":[{"code":"369","type":"RC"},{"code":"50520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Trabeculoplasty by laser surgery ","code_information":[{"code":"65855","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Unlisted laparoscopy procedure, rectum ","code_information":[{"code":"369","type":"RC"},{"code":"45499","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Replacement of indwelling bladder and peritoneal catheters, including tunneling of catheter(s) and connection with previously implanted peritoneal ascites pump, including imaging and programming, when ","code_information":[{"code":"0872T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":26334.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Open treatment of fracture of orbit, except blowout; without implant ","code_information":[{"code":"21406","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closure postauricular fistula, mastoid (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"69700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; 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medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) ","code_information":[{"code":"16025","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Immunoassay for tumor antigen, quantitative; CA 19-9 ","code_information":[{"code":"319","type":"RC"},{"code":"86301","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.810,"maximum":21.430,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.430,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas ","code_information":[{"code":"403","type":"RC"},{"code":"78801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each ","code_information":[{"code":"303","type":"RC"},{"code":"82787","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.020,"maximum":9.620,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.620,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.020,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.020,"methodology":"fee schedule"}]}]},{"description":"Non-sheet form skin substitute, fda cleared as a device, not otherwise specified (list in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"A4100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.980,"maximum":209.980,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.980,"methodology":"fee schedule"}]}]},{"description":"Orchiectomy, partial ","code_information":[{"code":"54522","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter ","code_information":[{"code":"76510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":63.710,"maximum":63.710,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":63.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":63.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":63.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":63.710,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":63.710,"methodology":"fee schedule"}]}]},{"description":"Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral ","code_information":[{"code":"62304","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0271U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":608.170,"maximum":729.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":620.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":729.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":620.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":729.800,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":626.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":608.170,"methodology":"fee schedule"}]}]},{"description":"Infectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per submitted isolate ","code_information":[{"code":"0010U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":427.260,"maximum":512.710,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":435.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":512.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":435.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":512.710,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":440.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":427.260,"methodology":"fee schedule"}]}]},{"description":"Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological s ","code_information":[{"code":"360","type":"RC"},{"code":"50695","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance ","code_information":[{"code":"360","type":"RC"},{"code":"49083","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; 5 cm or greater ","code_information":[{"code":"27364","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation onc ","code_information":[{"code":"323","type":"RC"},{"code":"77336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":92.870,"maximum":136.750,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":92.870,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":136.750,"methodology":"fee schedule"}]}]},{"description":"Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass ","code_information":[{"code":"32853","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":26334.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Dornase alfa, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram ","code_information":[{"code":"892","type":"RC"},{"code":"J7639","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":91.010,"maximum":91.010,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":91.010,"methodology":"fee schedule"}]}]},{"description":"Amputation, leg, through tibia and fibula; with immediate fitting technique including application of first cast ","code_information":[{"code":"27881","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recor ","code_information":[{"code":"360","type":"RC"},{"code":"93621","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":36180.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7591.060,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8611.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7591.060,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9233.710,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36180.000,"methodology":"case rate"}]}]},{"description":"Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; without subcutaneous port or pump (eg, Tesio type catheter) ","code_information":[{"code":"36565","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older ","code_information":[{"code":"360","type":"RC"},{"code":"36561","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance ","code_information":[{"code":"32554","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chemodenervation of extraocular muscle ","code_information":[{"code":"67345","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biopsy of vaginal mucosa; simple (separate procedure) ","code_information":[{"code":"57100","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session ","code_information":[{"code":"53447","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dermabind ch, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Splenectomy; partial (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"38101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment ","code_information":[{"code":"24359","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tonsillectomy, primary or secondary; age 12 or over ","code_information":[{"code":"42826","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) ","code_information":[{"code":"341","type":"RC"},{"code":"76512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Replacement of all or part of ureter by intestine segment, including intestine anastomosis ","code_information":[{"code":"50840","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Application of a modality to 1 or more areas; vasopneumatic devices ","code_information":[{"code":"97016","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.710,"maximum":12.050,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":11.590,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":21.58,"standard_charge_algorithm":"Reimbursement will be 21.58% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":11.820,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":11.480,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":11.590,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":11.590,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":11.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":11.480,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":10.710,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":11.480,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":11.480,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11.480,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":11.710,"methodology":"fee schedule"}]}]},{"description":"Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen or antibody ","code_information":[{"code":"319","type":"RC"},{"code":"86331","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.980,"maximum":12.340,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.340,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ve ","code_information":[{"code":"360","type":"RC"},{"code":"G0448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve ","code_information":[{"code":"64435","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"359","type":"RC"},{"code":"75891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3241.930,"maximum":3241.930,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3241.930,"methodology":"fee schedule"}]}]},{"description":"Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"58400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Escharotomy; initial incision ","code_information":[{"code":"16035","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm ","code_information":[{"code":"12046","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) ","code_information":[{"code":"0347T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7234.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"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"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":260.500,"maximum":312.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":265.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":312.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":265.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":312.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":268.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":260.500,"methodology":"fee schedule"}]}]},{"description":"Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician ","code_information":[{"code":"342","type":"RC"},{"code":"77331","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":136.750,"maximum":136.750,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":136.750,"methodology":"fee schedule"}]}]},{"description":"Plasma cryo redu path eac ","code_information":[{"code":"9538","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":133.760,"maximum":140.450,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":135.100,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":137.770,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":140.450,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":133.760,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":140.450,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":140.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":135.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":135.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":135.100,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":133.760,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":133.760,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":140.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":136.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":133.760,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":133.760,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":136.440,"methodology":"fee schedule"}]}]},{"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":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each ","code_information":[{"code":"26735","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7807.870,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nfct Agent HIV Trgt Viral Next-Gnrj Seq Alys Alg ","code_information":[{"code":"0219U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":725.000,"maximum":870.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":739.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":870.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":739.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":870.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":725.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":746.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":725.000,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm ","code_information":[{"code":"12037","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC One Day Stay","code_information":[{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Cordocentesis (intrauterine), any method ","code_information":[{"code":"59012","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) ","code_information":[{"code":"54700","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery ","code_information":[{"code":"59610","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed ","code_information":[{"code":"49325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":14081.810,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7966.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5690.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9829.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":9829.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9829.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14081.810,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13794.420,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with intraprocedural coronary ","code_information":[{"code":"790","type":"RC"},{"code":"C7570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Morphometric analysis; 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with operating microscope or telescope ","code_information":[{"code":"31536","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus ","code_information":[{"code":"64714","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Insertion of Heyman capsules for clinical brachytherapy ","code_information":[{"code":"499","type":"RC"},{"code":"58346","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Coagulation and fibrinolysis, functional activity, not otherwise specified (eg, ADAMTS-13), each analyte ","code_information":[{"code":"319","type":"RC"},{"code":"85397","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.860,"maximum":31.790,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":30.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":31.790,"methodology":"fee schedule"}]}]},{"description":"Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected ","code_information":[{"code":"0405U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1770.480,"maximum":2124.580,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1805.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2124.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1805.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2124.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1770.480,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1823.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1770.480,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection, glucagon (gvoke), 0.01 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J1612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.290,"maximum":4.290,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.290,"methodology":"fee schedule"}]}]},{"description":"Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed ","code_information":[{"code":"32408","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"STROKE; M > 30.05 & M < 34.25 ","code_information":[{"code":"118","type":"RC"},{"code":"D0106","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":36707.760,"maximum":40745.620,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":38910.230,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":36707.760,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":40745.620,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":38543.150,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":37074.840,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":37074.840,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":37074.840,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":36707.760,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":40745.620,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":40745.620,"methodology":"fee schedule"}]}]},{"description":"Ureterorrhaphy, suture of ureter (separate procedure) ","code_information":[{"code":"50900","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Incision and removal of foreign body, subcutaneous tissues; complicated ","code_information":[{"code":"10121","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance ","code_information":[{"code":"37187","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":18422.370,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":18422.370,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":18046.410,"methodology":"fee schedule"},{"payer_name":"Pruitt 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with vascular flow ","code_information":[{"code":"349","type":"RC"},{"code":"78202","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":35.460,"maximum":40.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":40.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":40.870,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS; M > 49.15 ","code_information":[{"code":"B2001","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":18740.360,"maximum":19525.200,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":19142.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18740.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":19142.350,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":19525.200,"methodology":"fee schedule"}]}]},{"description":"Acetabuloplasty; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"114","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1513.350,"maximum":1679.820,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1513.350,"methodology":"fee schedule","additional_payer_notes":"Days 1. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Suture of major peripheral nerve, arm or leg, except sciatic; including transposition ","code_information":[{"code":"361","type":"RC"},{"code":"64856","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; ","code_information":[{"code":"616","type":"RC"},{"code":"75557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Repair, diaphragmatic hernia (other than neonatal), traumatic; acute ","code_information":[{"code":"39540","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, cabotegravir and rilpivirine, 2mg/3mg ","code_information":[{"code":"343","type":"RC"},{"code":"J0741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":39.860,"maximum":39.860,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":39.860,"methodology":"fee schedule"}]}]},{"description":"CARDIAC; M > 48.85 ","code_information":[{"code":"148","type":"RC"},{"code":"C1401","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":14500.120,"maximum":16095.140,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":15370.130,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":14500.120,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":16095.140,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":15225.130,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14645.120,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":14645.120,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":14645.120,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":14500.120,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":16095.140,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":16095.140,"methodology":"fee schedule"}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space ","code_information":[{"code":"369","type":"RC"},{"code":"41018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; with subcutaneous port(s) ","code_information":[{"code":"36566","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"}]}]},{"description":"Impression and custom preparation; orbital prosthesis ","code_information":[{"code":"21077","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pneumonostomy, with open drainage of abscess or cyst ","code_information":[{"code":"32200","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Oncology (Solid Tumor), circulating tumor cell selection, id, morphological characterization, detection and enumeration based on differential EpCAM, cytokeratins 8, 18 and 19, and CD45 protein biomark ","code_information":[{"code":"0338U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2435.000,"maximum":2922.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2483.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2922.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2483.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2922.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2435.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2508.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2435.000,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; neck, soft tissue ","code_information":[{"code":"323","type":"RC"},{"code":"70360","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":35.990,"maximum":43.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":40.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":43.770,"methodology":"fee schedule"}]}]},{"description":"Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; 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Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot) ","code_information":[{"code":"312","type":"RC"},{"code":"86617","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.490,"maximum":15.950,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.950,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"63012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rhytidectomy; cheek, chin, and neck ","code_information":[{"code":"15828","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug ","code_information":[{"code":"310","type":"RC"},{"code":"81536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":177.560,"maximum":182.890,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":177.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":182.890,"methodology":"fee schedule"}]}]},{"description":"Infectious disease (urinary tract infection), identification of 17 pathologic organisms, urine, real-time PCR, reported as positive or negative for each organism ","code_information":[{"code":"0504U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":429.280,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":429.280,"methodology":"fee schedule"}]}]},{"description":"Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements ","code_information":[{"code":"0050U","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2916.600,"maximum":3004.100,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2916.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3004.100,"methodology":"fee schedule"}]}]},{"description":"Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure) ","code_information":[{"code":"38760","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus) ","code_information":[{"code":"87633","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":500.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":500.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":500.140,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":429.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.780,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. 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"}]}]},{"description":"OTHER CARDIOTHORACIC AND THORACIC CIRCULATORY PROCEDURES ","code_information":[{"code":"1673","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":34183.440,"maximum":34867.110,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":34183.440,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":34867.110,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":34183.440,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":34183.440,"methodology":"fee schedule"}]}]},{"description":"Disarticulation at knee ","code_information":[{"code":"27598","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft (includes obtaining graft), each tendon ","code_information":[{"code":"26352","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed ","code_information":[{"code":"45393","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant ","code_information":[{"code":"300","type":"RC"},{"code":"81283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":73.370,"maximum":88.040,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":74.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":88.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":74.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":88.040,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":73.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":75.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":73.370,"methodology":"fee schedule"}]}]},{"description":"Pleural scarification for repeat pneumothorax ","code_information":[{"code":"32215","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of patellar fracture, without manipulation ","code_information":[{"code":"27520","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; 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with manual screening and rescreening under physician supervision ","code_information":[{"code":"310","type":"RC"},{"code":"88165","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.220,"maximum":50.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.660,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":42.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":43.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":42.220,"methodology":"fee schedule"}]}]},{"description":"Drainage abscess or hematoma, nasal, internal approach ","code_information":[{"code":"30000","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incisionºs») ","code_information":[{"code":"27681","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of foreign body ","code_information":[{"code":"31635","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION, LOWER EXTREMITY; M > 36.25 & M < 47.65 ","code_information":[{"code":"118","type":"RC"},{"code":"C1002","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19981.560,"maximum":22179.530,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21180.450,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19981.560,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":22179.530,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20980.640,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20181.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20181.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20181.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19981.560,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":22179.530,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":22179.530,"methodology":"fee schedule"}]}]},{"description":"Lymphangiotomy or other operations on lymphatic channels ","code_information":[{"code":"360","type":"RC"},{"code":"38308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC Pediatric","code_information":[{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":39826.910,"maximum":55756.160,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":55756.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":55756.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":55756.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":55756.160,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":39826.910,"methodology":"fee schedule"}]}]},{"description":"Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or with ","code_information":[{"code":"49496","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PULMONARY; M > 39.05 & M < 49.25 ","code_information":[{"code":"138","type":"RC"},{"code":"C1502","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20751.510,"maximum":23034.170,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21996.600,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20751.510,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":23034.170,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":21789.080,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20959.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20959.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20959.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":20751.510,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":23034.170,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":23034.170,"methodology":"fee schedule"}]}]},{"description":"Injection, belinostat, 10 ","code_information":[{"code":"01658","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":51.520,"maximum":51.520,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":51.520,"methodology":"fee schedule"}]}]},{"description":"Tonsillectomy and adenoidectomy; younger than age 12 ","code_information":[{"code":"42820","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation) ","code_information":[{"code":"61343","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case 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logic."}]}]},{"description":"Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) ","code_information":[{"code":"329","type":"RC"},{"code":"77600","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":770.690,"maximum":937.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":770.690,"methodology":"fee 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logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, ","code_information":[{"code":"27036","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case 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Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; 5 cm or greater ","code_information":[{"code":"23078","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm ","code_information":[{"code":"17264","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, inc ","code_information":[{"code":"34711","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Artacent c, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Obstetrics (preeclampsia), biochemical assay of placental-growth factor, time-resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score for preeclampsia ","code_information":[{"code":"0243U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":64.410,"maximum":77.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":65.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":77.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":65.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":77.290,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":66.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":64.410,"methodology":"fee schedule"}]}]},{"description":"Craniotomy for craniosynostosis; bifrontal bone flap ","code_information":[{"code":"61557","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroplasty, elbow; with implant and fascia lata ligament reconstruction ","code_information":[{"code":"24362","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":15872.140,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15872.140,"methodology":"fee schedule","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury ","code_information":[{"code":"43840","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Neurology Alzheimer Disease Cell Aggregation ","code_information":[{"code":"0206U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2215.400,"maximum":2658.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2259.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2658.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2259.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2658.480,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2215.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2281.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2215.400,"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":1019.840,"maximum":1132.020,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1081.030,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1132.020,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1070.830,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1132.020,"methodology":"fee schedule","additional_payer_notes":"Days 9. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J0688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.450,"maximum":1.450,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1.450,"methodology":"fee schedule"}]}]},{"description":"Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score ","code_information":[{"code":"304","type":"RC"},{"code":"81522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3873.000,"maximum":3989.190,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3873.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3989.190,"methodology":"fee schedule"}]}]},{"description":"Amikacin ","code_information":[{"code":"304","type":"RC"},{"code":"80150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.080,"maximum":18.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.100,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.080,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.080,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cervical lymphadenectomy (complete) ","code_information":[{"code":"38720","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision of ileostomy; simple (release of superficial scar) (separate procedure) ","code_information":[{"code":"44312","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, axillary-brachial artery, by arm incision ","code_information":[{"code":"35013","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"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":1002.350,"maximum":1112.610,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1002.350,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1062.490,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1002.350,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1112.610,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1052.460,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1002.350,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1112.610,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1112.610,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar ","code_information":[{"code":"360","type":"RC"},{"code":"63170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":12227.700,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis ","code_information":[{"code":"311","type":"RC"},{"code":"86353","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.030,"maximum":50.500,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":49.030,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":50.500,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS; M > 49.15 ","code_information":[{"code":"118","type":"RC"},{"code":"B2001","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19142.350,"maximum":21248.010,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20290.890,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19142.350,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21248.010,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20099.470,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19333.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19333.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19333.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19142.350,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":21248.010,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":21248.010,"methodology":"fee schedule"}]}]},{"description":"Closure of rectovaginal fistula; vaginal or transanal approach ","code_information":[{"code":"369","type":"RC"},{"code":"57300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Removal and replacement of externally accessible nephroureteral catheter (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation ","code_information":[{"code":"480","type":"RC"},{"code":"50387","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment ","code_information":[{"code":"362","type":"RC"},{"code":"63081","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) ","code_information":[{"code":"15780","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm ","code_information":[{"code":"13151","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hepatitis A vaccine (HepA), adult dosage, for intramuscular use ","code_information":[{"code":"90632","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.000,"maximum":82.950,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":82.540,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":82.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":70.000,"methodology":"fee schedule"}]}]},{"description":"Removal of substernal implantable defibrillator pulse generator only ","code_information":[{"code":"0580T","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10376.500,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"}]}]},{"description":"Ultrasound, spinal canal and contents ","code_information":[{"code":"404","type":"RC"},{"code":"76800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, neck; without contrast material(s) ","code_information":[{"code":"612","type":"RC"},{"code":"70547","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia ","code_information":[{"code":"46045","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; with fulguration of oviducts (with or without transection) ","code_information":[{"code":"499","type":"RC"},{"code":"58670","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and rad ","code_information":[{"code":"37247","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"1-stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap) ","code_information":[{"code":"54322","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"3-dimensional radiotherapy plan, including dose-volume histograms ","code_information":[{"code":"342","type":"RC"},{"code":"77295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1409.310,"maximum":1409.310,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1409.310,"methodology":"fee schedule"}]}]},{"description":"Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation ","code_information":[{"code":"28300","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of anterior instrumentation ","code_information":[{"code":"22855","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft ","code_information":[{"code":"360","type":"RC"},{"code":"36825","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when performed; for aortic disease other than dissection (eg, aneurysm) ","code_information":[{"code":"33859","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring ","code_information":[{"code":"33426","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"49440","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification ","code_information":[{"code":"310","type":"RC"},{"code":"87652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.760,"maximum":43.010,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":43.010,"methodology":"fee schedule"}]}]},{"description":"Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guidance ","code_information":[{"code":"33019","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Radiologic examination, wrist; complete, minimum of 3 views ","code_information":[{"code":"324","type":"RC"},{"code":"73110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":68.300,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":68.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":77.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":68.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":83.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; femoral-femoral ","code_information":[{"code":"35661","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) ","code_information":[{"code":"22846","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Physician planning of a patient-specific fenestrated visceral aortic endograft requiring a minimum of 90 minutes of physician time ","code_information":[{"code":"34839","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5947.170,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesionºs») ","code_information":[{"code":"21048","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, mycophenolate mofetil, 10 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J7519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.610,"maximum":0.610,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.610,"methodology":"fee schedule"}]}]},{"description":"Revision or removal, lower esophageal sphincter neurostimulator pulse generator or receiver ","code_information":[{"code":"1015T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7548.000,"maximum":7548.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Excision of Mullerian duct cyst ","code_information":[{"code":"55680","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, agalsidase beta, 1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J0180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":380.030,"maximum":380.030,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":380.030,"methodology":"fee schedule"}]}]},{"description":"Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance ","code_information":[{"code":"20605","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Prescription drug, oral, chemotherapeutic, nos ","code_information":[{"code":"904558","type":"CDM"},{"code":"J8999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","gross_charge":1319.50,"discounted_cash":1319.50,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":21.58,"standard_charge_algorithm":"Reimbursement will be 21.58% of billable gross charges.","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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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, lumbosacral; minimum of 4 views ","code_information":[{"code":"612","type":"RC"},{"code":"72110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Transfusion, blood or blood components ","code_information":[{"code":"36430","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Brachytherapy source, non-stranded, yttrium-90, per source ","code_information":[{"code":"C2616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":43970.130,"maximum":44886.180,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":44886.180,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":43970.130,"methodology":"fee schedule"}]}]},{"description":"Injection, ferric derisomaltose, 10 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J1437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":37.670,"maximum":37.670,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":37.670,"methodology":"fee schedule"}]}]},{"description":"Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each ","code_information":[{"code":"27686","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Exploration of spinal fusion ","code_information":[{"code":"22830","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Open treatment of patellar dislocation, with or without partial or total patellectomy ","code_information":[{"code":"27566","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":13741.230,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracoscopy, surgical; with lobectomy (single lobe) ","code_information":[{"code":"32663","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition ","code_information":[{"code":"43761","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":611.610,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":624.350,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":611.610,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Preparation of moulage for custom breast implant ","code_information":[{"code":"19396","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy ºPOEM») ","code_information":[{"code":"43497","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) wit ","code_information":[{"code":"349","type":"RC"},{"code":"78832","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":1124.150,"maximum":1295.730,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1124.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1275.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1124.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1295.730,"methodology":"fee schedule"}]}]},{"description":"Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motionºs» and/or ejection fractionºs», when performed), dual radi ","code_information":[{"code":"321","type":"RC"},{"code":"78433","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":119.150,"maximum":2009.020,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":119.150,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2009.020,"methodology":"fee schedule"}]}]},{"description":"Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; ","code_information":[{"code":"361","type":"RC"},{"code":"50970","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List s ","code_information":[{"code":"37233","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":11386.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); 5 cm or greater ","code_information":[{"code":"27339","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; 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":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy ","code_information":[{"code":"15830","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without internal fixation, without bone graft ","code_information":[{"code":"61586","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision aural glomus tumor; transmastoid ","code_information":[{"code":"69552","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision or destruction (eg, laser), intranasal lesion; internal approach ","code_information":[{"code":"30117","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition ","code_information":[{"code":"361","type":"RC"},{"code":"G0453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Hereditary neuroendocrine tumor-related disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma), genomic sequence analysis panel, 5 or more gene ","code_information":[{"code":"81437","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":438.930,"maximum":1343.070,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":447.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":526.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":447.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":526.720,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1343.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":438.930,"methodology":"fee schedule"}]}]},{"description":"Brain imaging, positron emission tomography (PET); metabolic evaluation ","code_information":[{"code":"341","type":"RC"},{"code":"78608","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":103.000,"maximum":118.720,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":103.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":116.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":103.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":118.720,"methodology":"fee schedule"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC ","code_information":[{"code":"420","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15312.870,"maximum":16575.780,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":16575.780,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":15312.870,"methodology":"fee schedule"}]}]},{"description":"Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance ","code_information":[{"code":"32555","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube (eg, anticarcinogenic or antifungal agent) ","code_information":[{"code":"50391","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported ","code_information":[{"code":"0001U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":616.550,"maximum":864.000,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":727.200,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":756.000,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":741.600,"methodology":"fee 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schedule"}]}]},{"description":"Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angi ","code_information":[{"code":"36905","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of tissue expander(s) for other than breast, including subsequent expansion ","code_information":[{"code":"11960","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of lesion, conjunctiva; with adjacent sclera ","code_information":[{"code":"369","type":"RC"},{"code":"68130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling ","code_information":[{"code":"46947","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":6808.410,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":6808.410,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":6669.470,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hysterosalpingography, radiological supervision and interpretation ","code_information":[{"code":"404","type":"RC"},{"code":"74740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"Placement of drains, peripancreatic, for acute pancreatitis; with cholecystostomy, gastrostomy, and jejunostomy ","code_information":[{"code":"48001","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection ","code_information":[{"code":"43254","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Fascia lata graft; by incision and area exposure, complex or sheet ","code_information":[{"code":"20922","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7549.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm) ","code_information":[{"code":"361","type":"RC"},{"code":"64612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Surgery of intracranial arteriovenous malformation; supratentorial, simple ","code_information":[{"code":"362","type":"RC"},{"code":"61680","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VIRAL MENINGITIS WITH CC/MCC ","code_information":[{"code":"075","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5368.230,"maximum":5810.970,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":5810.970,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":5368.230,"methodology":"fee schedule"}]}]},{"description":"Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws ","code_information":[{"code":"24516","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Injection, gadopiclenol, 1 ml ","code_information":[{"code":"344","type":"RC"},{"code":"A9573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.450,"maximum":5.450,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.450,"methodology":"fee schedule"}]}]},{"description":"Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less ","code_information":[{"code":"15220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4695.840,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4695.840,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4600.000,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extrapleural enucleation of empyema (empyemectomy) ","code_information":[{"code":"32540","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion ","code_information":[{"code":"61736","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Operculectomy, excision pericoronal tissues ","code_information":[{"code":"369","type":"RC"},{"code":"41821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps ","code_information":[{"code":"29823","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Excision or fulguration of carcinoma of urethra ","code_information":[{"code":"360","type":"RC"},{"code":"53220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Urography, infusion, drip technique and/or bolus technique; with nephrotomography ","code_information":[{"code":"615","type":"RC"},{"code":"74415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Injection, ketorolac tromethamine, per 15 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J1885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.540,"maximum":0.540,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.540,"methodology":"fee schedule"}]}]},{"description":"Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy ","code_information":[{"code":"481","type":"RC"},{"code":"61323","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Hepatectomy, resection of liver; total right lobectomy ","code_information":[{"code":"47130","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin-embedded (FFPE) tissue, saliva, buccal swabs or cell ","code_information":[{"code":"0265U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5475.800,"maximum":6570.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5585.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6570.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5585.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6570.960,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5475.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5640.070,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5475.800,"methodology":"fee schedule"}]}]},{"description":"Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness) ","code_information":[{"code":"361","type":"RC"},{"code":"45171","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor, proximal or middle phalanx of finger ","code_information":[{"code":"26260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7807.870,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of penile prosthesis; inflatable (self-contained) ","code_information":[{"code":"481","type":"RC"},{"code":"54401","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4403.000,"maximum":33901.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":27870.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":31615.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":27870.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33901.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4403.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":30150.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic (CT) colonography, screening, including image postprocessing ","code_information":[{"code":"615","type":"RC"},{"code":"74263","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"Suture of facial nerve; extracranial ","code_information":[{"code":"64864","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, femur or knee ","code_information":[{"code":"27599","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vitamin, not otherwise specified ","code_information":[{"code":"304","type":"RC"},{"code":"84591","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.060,"maximum":20.470,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.470,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.060,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.060,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty wh ","code_information":[{"code":"37278","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction) ","code_information":[{"code":"300","type":"RC"},{"code":"81340","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":208.920,"maximum":250.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":213.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":250.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":213.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":250.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":208.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":215.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":208.920,"methodology":"fee schedule"}]}]},{"description":"Necropsy (autopsy), gross examination only; with brain and spinal cord ","code_information":[{"code":"310","type":"RC"},{"code":"88007","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":257.160,"maximum":308.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":262.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":308.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":262.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":308.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":257.160,"methodology":"fee schedule"}]}]},{"description":"Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary pr ","code_information":[{"code":"15101","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pma skin substitute product, not otherwise specified (list in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"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":"352","type":"RC"},{"code":"78430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1502.350,"maximum":1502.350,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1502.350,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage abscess; peritonsillar ","code_information":[{"code":"42700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":583.970,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":596.130,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":583.970,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJ MULT TRAUMA NO BRAIN OR SPINAL CORD INJURY; M ","code_information":[{"code":"148","type":"RC"},{"code":"B1703","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":30730.210,"maximum":34110.530,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":32574.020,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":30730.210,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":34110.530,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":32266.720,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":31037.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":31037.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":31037.510,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":30730.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":34110.530,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":34110.530,"methodology":"fee schedule"}]}]},{"description":"Intersex surgery; male to female ","code_information":[{"code":"55970","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":10874.200,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":10874.200,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":10652.280,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, pharynx, adenoids, or tonsils ","code_information":[{"code":"42999","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC BRAIN INJURY; M > 28.75 & M < 40.65 ","code_information":[{"code":"138","type":"RC"},{"code":"A0205","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":29953.820,"maximum":33248.740,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":31751.050,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":29953.820,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":33248.740,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":31451.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":30253.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":30253.360,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":30253.360,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":29953.820,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":33248.740,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":33248.740,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH O.R. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Pulmonary artery embolectomy; without cardiopulmonary bypass ","code_information":[{"code":"33915","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cardiology (cardiovascular disease), analysis of 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported ","code_information":[{"code":"0309U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":390.750,"maximum":402.470,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":390.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":402.470,"methodology":"fee schedule"}]}]},{"description":"Beta-amyloid; 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3 phase study ","code_information":[{"code":"611","type":"RC"},{"code":"78315","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Injection, fosdenopterin, 0.1 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J1809","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":28.450,"maximum":28.450,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":28.450,"methodology":"fee schedule"}]}]},{"description":"Craniotomy with elevation of bone flap; for excision of craniopharyngioma ","code_information":[{"code":"61545","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagoscopy, rigid, transoral; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction ","code_information":[{"code":"44615","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical ","code_information":[{"code":"22210","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, axillary; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Realignment of extensor tendon, hand, each tendon ","code_information":[{"code":"26437","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Patellectomy or hemipatellectomy ","code_information":[{"code":"27350","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) ","code_information":[{"code":"19100","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Platelet pheres leukoredu ","code_information":[{"code":"09501","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":496.240,"maximum":496.240,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":496.240,"methodology":"fee schedule"}]}]},{"description":"Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) ","code_information":[{"code":"15769","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm ","code_information":[{"code":"13120","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC One Day Stay","code_information":[{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"27893","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Excision of extraparenchymal lesion of testis ","code_information":[{"code":"360","type":"RC"},{"code":"54512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"116","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1083.580,"maximum":1202.770,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1148.590,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1083.580,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1083.580,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1202.770,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1202.770,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele ","code_information":[{"code":"499","type":"RC"},{"code":"58270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"302","type":"RC"},{"code":"87428","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.290,"maximum":88.340,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":75.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":88.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":75.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":88.340,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":70.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":72.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":73.620,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of patellar dislocation; without anesthesia ","code_information":[{"code":"27560","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral ","code_information":[{"code":"369","type":"RC"},{"code":"62304","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis ","code_information":[{"code":"400","type":"RC"},{"code":"75898","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":160.860,"maximum":195.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":160.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":182.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":160.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":195.610,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy ","code_information":[{"code":"43262","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3 ºplatelet glycoprotein IIIa», antigen CD61 ºGPIIIa») (eg, neonatal alloimmune thrombocytopenia ºNAIT», post-transfusion purpura), g ","code_information":[{"code":"305","type":"RC"},{"code":"81105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":122.220,"maximum":146.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":124.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":146.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":124.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":146.660,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":122.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":122.220,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hand; minimum of 3 views ","code_information":[{"code":"619","type":"RC"},{"code":"73130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY ","code_information":[{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13500.000,"maximum":62022.220,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":56899.840,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":22743.430,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":56899.840,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":56899.840,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":56899.840,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":40642.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":50988.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":57840.980,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":23193.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":50988.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":62022.220,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":28147.810,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":22968.620,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":22968.620,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":29620.920,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":23418.980,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":30954.560,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":23418.980,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":23215.920,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22743.430,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":22743.430,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":22743.430,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":22518.250,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":23418.980,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":29016.410,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":23418.980,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":23644.160,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22045.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":22518.250,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":22518.250,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":22968.620,"methodology":"fee schedule"}]}]},{"description":"Injection, lenacapavir (only for use as hiv treatment), 1 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J1961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":36.800,"maximum":36.800,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36.800,"methodology":"fee schedule"}]}]},{"description":"Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist ","code_information":[{"code":"929","type":"RC"},{"code":"95810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2362.000,"maximum":2933.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2411.290,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2735.350,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2411.290,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2933.080,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2362.000,"methodology":"case rate"}]}]},{"description":"Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture) ","code_information":[{"code":"362","type":"RC"},{"code":"64876","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tissue culture for neoplastic disorders; bone marrow, blood cells ","code_information":[{"code":"305","type":"RC"},{"code":"88237","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":143.750,"maximum":148.060,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":143.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":148.060,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"323","type":"RC"},{"code":"73206","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":343.620,"maximum":417.850,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":343.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":389.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":343.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":417.850,"methodology":"fee schedule"}]}]},{"description":"Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) ","code_information":[{"code":"15769","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) ","code_information":[{"code":"611","type":"RC"},{"code":"72196","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":828.270,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency) ","code_information":[{"code":"46930","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, pharynx, adenoids, or tonsils ","code_information":[{"code":"42999","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmon ","code_information":[{"code":"32855","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance ","code_information":[{"code":"490","type":"RC"},{"code":"61751","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Fetal shunt placement, including ultrasound guidance ","code_information":[{"code":"361","type":"RC"},{"code":"59076","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) ","code_information":[{"code":"350","type":"RC"},{"code":"77307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":377.050,"maximum":377.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":377.050,"methodology":"fee schedule"}]}]},{"description":"Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple (ie, valvotomy, debridement, debulking, and/or simple commissural resuspension) ","code_information":[{"code":"33390","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"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":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75891","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":116.730,"maximum":141.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":116.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":132.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":116.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":141.950,"methodology":"fee schedule"}]}]},{"description":"Insertion of pacemaker pulse generator only; with existing single lead ","code_information":[{"code":"33212","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":40210.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12396.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14062.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12396.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15079.200,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":38190.000,"methodology":"case rate"}]}]},{"description":"Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"58110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Esophagoplasty (plastic repair or reconstruction), thoracic approach; without repair of tracheoesophageal fistula ","code_information":[{"code":"43310","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; abdominal aorta ","code_information":[{"code":"0236T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4613.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical ","code_information":[{"code":"480","type":"RC"},{"code":"63020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Prolactin ","code_information":[{"code":"304","type":"RC"},{"code":"84146","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.380,"maximum":23.260,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.260,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":19.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19.380,"methodology":"fee schedule"}]}]},{"description":"Neurectomy, popliteal (gastrocnemius) ","code_information":[{"code":"27326","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique ","code_information":[{"code":"811727","type":"CDM"},{"code":"87496","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.150,"maximum":42.110,"gross_charge":1207.75,"discounted_cash":1207.75,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":28.980,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":36.140,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":28.150,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":30.050,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"}]}]},{"description":"Craniectomy for craniosynostosis; multiple cranial sutures ","code_information":[{"code":"499","type":"RC"},{"code":"61552","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and eletion/duplication analysis panel (A ","code_information":[{"code":"0129U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1303.950,"maximum":1343.070,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1303.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1343.070,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10550.000,"maximum":37397.960,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":34309.280,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":14404.600,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":34309.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":34309.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":34309.280,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":24506.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":30745.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":34876.760,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":14689.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":30745.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":37397.960,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":17827.470,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":14547.220,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":14547.220,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":18247.860,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":14832.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18664.880,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":14832.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":13998.660,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14404.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":14404.600,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":14404.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":14261.980,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":14832.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11221.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":17875.460,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":14832.460,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14975.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10550.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13962.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":14261.980,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":14261.980,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":14547.220,"methodology":"fee schedule"}]}]},{"description":"Calcitonin ","code_information":[{"code":"302","type":"RC"},{"code":"82308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.790,"maximum":32.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":27.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":27.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32.150,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":26.790,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":26.790,"methodology":"fee schedule"}]}]},{"description":"Exposure of prostate, any approach, for insertion of radioactive substance; 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2 views ","code_information":[{"code":"341","type":"RC"},{"code":"73521","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"APPLY SKN XENOGRFT T/A/L ADD ","code_information":[{"code":"15401","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm ","code_information":[{"code":"17272","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":499.670,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":510.080,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":499.670,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HLigation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) ","code_information":[{"code":"55450","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Arthrotomy, wrist joint; with biopsy ","code_information":[{"code":"25100","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Colpocentesis (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"57020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Nasal smear for eosinophils ","code_information":[{"code":"305","type":"RC"},{"code":"89190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.790,"maximum":6.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.950,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.790,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.790,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of Bartholin's gland abscess ","code_information":[{"code":"56420","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"204","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1130.100,"maximum":1130.100,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1130.100,"methodology":"fee schedule","additional_payer_notes":"Days 3. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Magnetic resonance angiography, neck; without contrast material(s) ","code_information":[{"code":"359","type":"RC"},{"code":"70547","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of mandibular fracture with interdental fixation ","code_information":[{"code":"21453","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) Neck/Spine","code_information":[{"code":"22843","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13504.100,"maximum":16426.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15318.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16426.200,"methodology":"case rate"}]}]},{"description":"Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in ","code_information":[{"code":"34713","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of subdeltoid calcareous deposits, open ","code_information":[{"code":"23000","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Neck/Spine","code_information":[{"code":"22841","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13504.100,"maximum":16426.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15318.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16426.200,"methodology":"case rate"}]}]},{"description":"Removal of ocular implant ","code_information":[{"code":"65175","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral ","code_information":[{"code":"15576","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm ","code_information":[{"code":"12032","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NEUROLOGICAL; M < 25.85 ","code_information":[{"code":"128","type":"RC"},{"code":"B0604","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":39460.560,"maximum":43801.220,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":41828.200,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":39460.560,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":43801.220,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":41433.590,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":39855.170,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":39855.170,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":39855.170,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":39460.560,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":43801.220,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":43801.220,"methodology":"fee schedule"}]}]},{"description":"SMPD1 (sphingomyelin phosphodiesterase 1, acid lysosomal) (eg, Niemann-Pick disease, Type A) gene analysis, common variants (eg, R496L, L302P, fsP330) ","code_information":[{"code":"304","type":"RC"},{"code":"81330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":47.000,"maximum":56.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":47.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":47.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":56.400,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":47.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":48.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":47.000,"methodology":"fee schedule"}]}]},{"description":"Lengthening of palate, and pharyngeal flap ","code_information":[{"code":"42226","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, abdomen; 2 views ","code_information":[{"code":"74019","type":"CPT"},{"code":"825409","type":"CDM"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":267.420,"maximum":272.990,"gross_charge":701.25,"discounted_cash":701.25,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":272.990,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":267.420,"methodology":"fee schedule"}]}]},{"description":"Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal fixation, when performed ","code_information":[{"code":"27514","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, abdominal, real time with image documentation; complete ","code_information":[{"code":"349","type":"RC"},{"code":"76700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Heterophile antibodies; titers after absorption with beef cells and guinea pig kidney ","code_information":[{"code":"311","type":"RC"},{"code":"86310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.370,"maximum":7.590,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.590,"methodology":"fee schedule"}]}]},{"description":"Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacement of conduit from right or left ventricle to pulmonary artery ","code_information":[{"code":"33608","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"Removal of embedded foreign body, eyelid ","code_information":[{"code":"67938","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Release, intrinsic muscles of hand, each muscle ","code_information":[{"code":"26593","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) ","code_information":[{"code":"23802","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft ","code_information":[{"code":"24342","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) ","code_information":[{"code":"36833","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision ","code_information":[{"code":"88147","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":52.080,"maximum":52.080,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":52.080,"methodology":"fee schedule"}]}]},{"description":"OSTEOARTHRITIS; M < 30.75 ","code_information":[{"code":"B1203","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":32879.210,"maximum":34256.180,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":33584.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":32879.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":33584.490,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":34256.180,"methodology":"fee schedule"}]}]},{"description":"Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervi ","code_information":[{"code":"47534","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm) ","code_information":[{"code":"64612","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenotomy, shoulder area; single tendon ","code_information":[{"code":"23405","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Trimethylamine/trimethylamine N-oxide (TMA/TMAO) profile, tandem mass spectrometry (MS/MS), urine, with algorithmic analysis and interpretive report ","code_information":[{"code":"0256U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":159.950,"maximum":164.750,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":159.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":164.750,"methodology":"fee schedule"}]}]},{"description":"Esophagoplasty (plastic repair or reconstruction), thoracic approach; with repair of tracheoesophageal fistula ","code_information":[{"code":"43312","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Banding of pulmonary artery ","code_information":[{"code":"33690","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":1094.310,"maximum":1214.680,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1094.310,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1159.960,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1094.310,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1214.680,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1149.020,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1094.310,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1214.680,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1214.680,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code) ","code_information":[{"code":"15854","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Syndactylization, toes (eg, webbing or Kelikian type procedure) ","code_information":[{"code":"28280","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Removal of lens material; aspiration technique, 1 or more stages ","code_information":[{"code":"362","type":"RC"},{"code":"66840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Post-coital direct, qualitative examinations of vaginal or cervical mucous ","code_information":[{"code":"923","type":"RC"},{"code":"Q0115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":25.000,"maximum":30.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":30.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":25.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.000,"methodology":"fee schedule"}]}]},{"description":"Repair of coronary arteriovenous or arteriocardiac chamber fistula; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"}]}]},{"description":"Repair sinus of Valsalva fistula, with cardiopulmonary bypass; ","code_information":[{"code":"33702","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of neurofibroma or neurolemmoma; extensive (including malignant type) ","code_information":[{"code":"64792","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Unlisted endocrine procedure, diagnostic nuclear medicine ","code_information":[{"code":"359","type":"RC"},{"code":"78099","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Sialolithotomy; submandibular (submaxillary), complicated, intraoral ","code_information":[{"code":"42335","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Proton treatment delivery; complex ","code_information":[{"code":"400","type":"RC"},{"code":"77525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1313.780,"maximum":1313.780,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1313.780,"methodology":"fee schedule"}]}]},{"description":"Avulsion of nail plate, partial or complete, simple; single ","code_information":[{"code":"11730","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, primary, torn ligament and/or capsule, knee; collateral ","code_information":[{"code":"27405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":13741.230,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1120.810,"maximum":1244.100,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1188.060,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1120.810,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1120.810,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1244.100,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1244.100,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Repair blood vessel with vein graft; upper extremity ","code_information":[{"code":"35236","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure) ","code_information":[{"code":"323","type":"RC"},{"code":"76125","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":21.530,"maximum":26.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26.180,"methodology":"fee schedule"}]}]},{"description":"Sedimentation rate, erythrocyte; 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2 views ","code_information":[{"code":"342","type":"RC"},{"code":"73521","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; ","code_information":[{"code":"362","type":"RC"},{"code":"59855","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; extradural ","code_information":[{"code":"61605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj ruxience, 10 mg ","code_information":[{"code":"9367","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":13.270,"maximum":13.930,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":13.400,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":13.670,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":13.270,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13.400,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":13.400,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":13.400,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":13.270,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":13.270,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":13.270,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":13.270,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":13.540,"methodology":"fee schedule"}]}]},{"description":"Endomyocardial biopsy ","code_information":[{"code":"750","type":"RC"},{"code":"93505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4368.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Excision of thyroglossal duct cyst or sinus; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Intracavitary radiation source application; complex ","code_information":[{"code":"400","type":"RC"},{"code":"77763","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":714.620,"maximum":1519.210,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1249.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1417.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1249.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1519.210,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":714.620,"methodology":"fee schedule"}]}]},{"description":"Repair of tunica vaginalis hydrocele (Bottle type) ","code_information":[{"code":"362","type":"RC"},{"code":"55060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre-procedure sizing ","code_information":[{"code":"34718","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"838","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7276.070,"maximum":7876.160,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":7876.160,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":7276.070,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body, shoulder; deep (subfascial or intramuscular) ","code_information":[{"code":"23333","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Angiography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"75710","type":"CPT"},{"code":"806460","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":141.560,"maximum":141.560,"gross_charge":31433.25,"discounted_cash":31433.25,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":141.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":141.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":141.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":141.560,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":141.560,"methodology":"fee schedule"}]}]},{"description":"Hydroxyprogesterone, 17-d ","code_information":[{"code":"83498","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.170,"maximum":32.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":27.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":27.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27.170,"methodology":"fee schedule"}]}]},{"description":"Neurectomy, popliteal (gastrocnemius) ","code_information":[{"code":"27326","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, midtarsal or tarsometatarsal, single joint ","code_information":[{"code":"28740","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar ","code_information":[{"code":"62292","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, humerus; ","code_information":[{"code":"24110","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Thoracostomy; with open flap drainage for empyema ","code_information":[{"code":"32036","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, ribs, bilateral; 3 views ","code_information":[{"code":"320","type":"RC"},{"code":"71110","type":"CPT"},{"code":"801776","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":48.800,"maximum":245.180,"gross_charge":1163.00,"discounted_cash":1163.00,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":67.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":77.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":67.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":82.680,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":48.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Excision, lesion of palate, uvula; with simple primary closure ","code_information":[{"code":"42106","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8193.780,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH MCC One Day Stay","code_information":[{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. 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logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Perirectal injection of sclerosing solution for prolapse ","code_information":[{"code":"45520","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2, screening ","code_information":[{"code":"303","type":"RC"},{"code":"G0432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":19.570,"maximum":23.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.480,"methodology":"fee schedule"},{"payer_name":"Friday 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logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), ","code_information":[{"code":"34703","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use ","code_information":[{"code":"343","type":"RC"},{"code":"90651","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":651.350,"maximum":651.350,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":651.350,"methodology":"fee 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Antidepressants, tricyclic and other cyclicals; 1 or 2 ","code_information":[{"code":"80335","type":"CPT"},{"code":"822854","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":25.680,"maximum":26.440,"gross_charge":241.75,"discounted_cash":241.75,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":26.440,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":25.680,"methodology":"fee schedule"}]}]},{"description":"Gonadotropin, chorionic (hCG); quantitative 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finger ","code_information":[{"code":"26428","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple ","code_information":[{"code":"38570","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":" Other Therapeutic Services Other Therapeutic Service  ","code_information":[{"code":"949","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":251.000,"maximum":942.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":774.580,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":878.690,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":774.580,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":942.200,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":251.000,"methodology":"case rate"}]}]},{"description":"Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed ","code_information":[{"code":"44158","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MALIGNANT BREAST DISORDERS ","code_information":[{"code":"3821","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3862.540,"maximum":3939.790,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":3862.540,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":3939.790,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":3862.540,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":3862.540,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, elbow; with synovial biopsy only ","code_information":[{"code":"24100","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervi ","code_information":[{"code":"47534","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenotomy, adductor of hip, percutaneous (separate procedure) ","code_information":[{"code":"27000","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance ","code_information":[{"code":"62328","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Craniotomy for craniosynostosis; frontal or parietal bone flap ","code_information":[{"code":"61556","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, argatroban (auromedics), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis) ","code_information":[{"code":"891","type":"RC"},{"code":"J0899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.390,"maximum":2.390,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2.390,"methodology":"fee schedule"}]}]},{"description":"Thyroxine binding globulin (TBG) ","code_information":[{"code":"301","type":"RC"},{"code":"805294","type":"CDM"},{"code":"84442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.780,"maximum":17.740,"gross_charge":184.00,"discounted_cash":184.00,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.740,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.220,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.780,"methodology":"fee schedule"}]}]},{"description":"Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any ","code_information":[{"code":"329","type":"RC"},{"code":"77001","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":130.360,"maximum":158.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":130.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":147.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":130.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":158.520,"methodology":"fee schedule"}]}]},{"description":"Chemodenervation of eccrine glands; both axillae ","code_information":[{"code":"360","type":"RC"},{"code":"64650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Manipulation of spine requiring anesthesia, any region ","code_information":[{"code":"22505","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inj., emapalumab-lzsg, 1 ","code_information":[{"code":"09310","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":372.610,"maximum":372.610,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":372.610,"methodology":"fee schedule"}]}]},{"description":"Esophagogastric tamponade, with balloon (Sengstaken type) ","code_information":[{"code":"43460","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Endovascular stent repair of coarctation of the ascending, transverse, or descending thoracic or abdominal aorta, involving stent placement; across major side branches ","code_information":[{"code":"33894","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"HLA Class I and II typing, high resolution (ie, alleles or allele groups), HLA-A, -B, -C, and -DRB1 ","code_information":[{"code":"301","type":"RC"},{"code":"81378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":345.570,"maximum":414.680,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":352.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":414.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":352.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":414.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":345.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":355.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":345.570,"methodology":"fee schedule"}]}]},{"description":"Injection, fluphenazine hcl, 1.25 mg ","code_information":[{"code":"J2679","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":6.940,"maximum":19.740,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":9.330,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":8.160,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":19.740,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":6.940,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":19.330,"methodology":"fee schedule"}]}]},{"description":"CLOSED TREATMENT OF NASAL BONE FRACTURE WITHOUT MANIPULATION ","code_information":[{"code":"21310","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Culture, typing; identification of blood pathogen and resistance typing, when performed, by nucleic acid (DNA or RNA) probe, multiplexed amplified probe technique including multiplex reverse transcrip ","code_information":[{"code":"314","type":"RC"},{"code":"87154","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":218.060,"maximum":224.600,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":218.060,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":224.600,"methodology":"fee schedule"}]}]},{"description":"Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; ","code_information":[{"code":"51590","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Exenteration of orbit (does not include skin graft), removal of orbital contents; with muscle or myocutaneous flap ","code_information":[{"code":"65114","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection, sirolimus protein-bound particles, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J9331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":143.730,"maximum":143.730,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":143.730,"methodology":"fee schedule"}]}]},{"description":"Injection, glycopyrrolate (fresenius kabi), not therapeutically equivalent to j1596, 0.1 mg ","code_information":[{"code":"J1598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.610,"maximum":5.180,"payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":2.220,"methodology":"fee schedule"},{"payer_name":"Employer's Health 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adjusted for multiple procedure logic."}]}]},{"description":"Buccal/ labial frenectomy (frenulectomy) ","code_information":[{"code":"481","type":"RC"},{"code":"D7961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Bone marrow imaging; whole body ","code_information":[{"code":"350","type":"RC"},{"code":"78104","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique ","code_information":[{"code":"306","type":"RC"},{"code":"87485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.050,"maximum":24.060,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.050,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, elastography; first target lesion ","code_information":[{"code":"329","type":"RC"},{"code":"76982","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, with bronchial alveolar lavage and transendoscopic endobronchial ultrasound (ebus) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion ","code_information":[{"code":"490","type":"RC"},{"code":"C7556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10391.800,"maximum":12640.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11788.400,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12640.500,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Removal of lens material; extracapsular (other than 66840, 66850, 66852) ","code_information":[{"code":"362","type":"RC"},{"code":"66940","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, fluphenazine decanoate, up to 25 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J2680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":10.230,"maximum":10.230,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.230,"methodology":"fee schedule"}]}]},{"description":"Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum ","code_information":[{"code":"11004","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, ","code_information":[{"code":"27036","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery ","code_information":[{"code":"35666","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) ","code_information":[{"code":"23575","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery ","code_information":[{"code":"37254","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and ","code_information":[{"code":"490","type":"RC"},{"code":"62369","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, avacincaptad pegol, 0.1 mg ","code_information":[{"code":"343","type":"RC"},{"code":"J2782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":169.820,"maximum":169.820,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":169.820,"methodology":"fee schedule"}]}]},{"description":"Sesamoidectomy, first toe (separate procedure) ","code_information":[{"code":"28315","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); with fluoroscopic or CT guidance ","code_information":[{"code":"62329","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, multiples amplified probe technique, vaginal, endocervical, or male urine, each pathogen r ","code_information":[{"code":"0402U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":122.130,"maximum":149.760,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":146.910,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":145.480,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":144.060,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":122.130,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":149.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":145.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":145.480,"methodology":"fee schedule"}]}]},{"description":"Rabies immune globulin, heat- and solvent/detergent-treated (RIg-HT S/D), human, for intramuscular and/or subcutaneous use ","code_information":[{"code":"891","type":"RC"},{"code":"90377","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":396.210,"maximum":396.210,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":396.210,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"24076","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"136","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":835.740,"maximum":927.670,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":885.880,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":835.740,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":835.740,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":927.670,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":927.670,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Repair blood vessel with vein graft; neck ","code_information":[{"code":"35231","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of ventricular assist device; extracorporeal, biventricular ","code_information":[{"code":"33978","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel ","code_information":[{"code":"320","type":"RC"},{"code":"77767","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":315.830,"maximum":384.060,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":315.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":358.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":315.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":384.060,"methodology":"fee schedule"}]}]},{"description":"Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion ","code_information":[{"code":"61450","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, fosaprepitant (focinvez), 1 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J1434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.340,"maximum":4.340,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.340,"methodology":"fee schedule"}]}]},{"description":"Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture ","code_information":[{"code":"33991","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition ","code_information":[{"code":"11922","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube ","code_information":[{"code":"68745","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Phosphorus inorganic (phosphate); ","code_information":[{"code":"84100","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4.740,"maximum":5.690,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.690,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.740,"methodology":"fee schedule"}]}]},{"description":"Incision and removal of foreign body, subcutaneous tissues; complicated ","code_information":[{"code":"10121","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cross finger flap ","code_information":[{"code":"15580","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","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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simple ","code_information":[{"code":"52310","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft; composite, prosthetic and vein (List separately in addition to code for primary procedure) ","code_information":[{"code":"35681","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Lacosamide ","code_information":[{"code":"306","type":"RC"},{"code":"80235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.110,"maximum":32.530,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":27.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":27.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":32.530,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":27.110,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D194K9","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17085.000,"maximum":17085.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17085.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixat ","code_information":[{"code":"25526","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Thymectomy, partial or total; sternal split or transthoracic approach, with radical mediastinal dissection (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"60522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Replacement of sub-scalp implanted electrode array, receiver, and telemetry unit with tunneling of electrode for continuous bilateral electroencephalography monitoring system, including imaging guidan ","code_information":[{"code":"0960T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":25200.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25200.000,"methodology":"case rate"}]}]},{"description":"Percutaneous pulmonary artery revascularization by stent placement, each additional vessel or separate lesion, normal or abnormal connections (List separately in addition to code for primary procedure ","code_information":[{"code":"33904","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter placement and subsequent removal of cerebral embolic protection device(s), including arterial access, catheterization, imaging, and radiological supervision and interpretation, percutane ","code_information":[{"code":"33370","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone length studies (orthoroentgenogram, scanogram) ","code_information":[{"code":"616","type":"RC"},{"code":"77073","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants ","code_information":[{"code":"301","type":"RC"},{"code":"81212","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":440.000,"maximum":528.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":448.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":528.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":448.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":528.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":440.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":453.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":440.000,"methodology":"fee schedule"}]}]},{"description":"Periodontal mucosal grafting ","code_information":[{"code":"41870","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant ","code_information":[{"code":"311","type":"RC"},{"code":"81323","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":300.000,"maximum":309.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":300.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":309.000,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body in muscle or tendon sheath; deep or complicated ","code_information":[{"code":"20525","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, lanreotide, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J1930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":58.390,"maximum":58.390,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":58.390,"methodology":"fee schedule"}]}]},{"description":"FRACTURE OF LOWER EXTREMITY; M < 28.15 ","code_information":[{"code":"138","type":"RC"},{"code":"C0704","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":29544.680,"maximum":32794.600,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":31317.360,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":29544.680,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":32794.600,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":31021.920,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":29840.130,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":29840.130,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":29840.130,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":29544.680,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":32794.600,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":32794.600,"methodology":"fee schedule"}]}]},{"description":"Therapeutic apheresis; for red blood cells ","code_information":[{"code":"36512","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Exploration not followed by surgical repair, artery; lower extremity (eg, common femoral, deep femoral, superficial femoral, popliteal, tibial, peroneal) ","code_information":[{"code":"35703","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, great toe; metatarsophalangeal joint ","code_information":[{"code":"28750","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Placement of choledochal stent ","code_information":[{"code":"47801","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery ","code_information":[{"code":"37254","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic ","code_information":[{"code":"490","type":"RC"},{"code":"63016","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Closure of rectovaginal fistula; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Drainage of scrotal wall abscess ","code_information":[{"code":"55100","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes ","code_information":[{"code":"361","type":"RC"},{"code":"55865","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":25139.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23445.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25139.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11055.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic ","code_information":[{"code":"614","type":"RC"},{"code":"72157","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":828.270,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. 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"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 5+. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection of sclerosing solution, hemorrhoids ","code_information":[{"code":"369","type":"RC"},{"code":"46500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Fetal biophysical profile; without non-stress testing ","code_information":[{"code":"402","type":"RC"},{"code":"76819","type":"CPT"},{"code":"802239","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":245.180,"gross_charge":2055.00,"discounted_cash":2055.00,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":138.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":157.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":138.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":169.020,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, liver ","code_information":[{"code":"369","type":"RC"},{"code":"47399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Thiamine (Vitamin B-1) ","code_information":[{"code":"312","type":"RC"},{"code":"84425","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.230,"maximum":21.870,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.230,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.870,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC ","code_information":[{"code":"122","type":"RC"},{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Surgical treatment of anal fistula (fistulectomy/fistulotomy); transsphincteric, suprasphincteric, extrasphincteric or multiple, including placement of seton, when performed ","code_information":[{"code":"46280","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax ","code_information":[{"code":"21510","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"57267","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"73219","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":115.490,"maximum":140.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":115.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":130.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":115.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":140.440,"methodology":"fee schedule"}]}]},{"description":"Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter ","code_information":[{"code":"15050","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sedimentation rate, erythrocyte; automated ","code_information":[{"code":"85652","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2.700,"maximum":3.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.240,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2.700,"methodology":"fee schedule"}]}]},{"description":"Osteoplasty, carpal bone, shortening ","code_information":[{"code":"25394","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Exploration not followed by surgical repair, artery; lower extremity (eg, common femoral, deep femoral, superficial femoral, popliteal, tibial, peroneal) ","code_information":[{"code":"35703","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit ","code_information":[{"code":"32653","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) ","code_information":[{"code":"37222","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":10520.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pregnenolone ","code_information":[{"code":"84140","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":20.670,"maximum":24.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.670,"methodology":"fee schedule"}]}]},{"description":"Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation ","code_information":[{"code":"361","type":"RC"},{"code":"67210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Antibody; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Alveolectomy, including curettage of osteitis or sequestrectomy ","code_information":[{"code":"41830","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision (including removal) of prosthetic vaginal graft; vaginal approach ","code_information":[{"code":"57295","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; 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single tendon ","code_information":[{"code":"28010","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of metatarsophalangeal joint dislocation; without anesthesia ","code_information":[{"code":"28630","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Ligation, direct, esophageal varices ","code_information":[{"code":"369","type":"RC"},{"code":"43400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Excision, lesion of palate, uvula; with simple primary closure ","code_information":[{"code":"42106","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance angiography, head; with contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"70545","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":84.880,"maximum":103.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":84.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":96.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":84.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":103.220,"methodology":"fee schedule"}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy ","code_information":[{"code":"50555","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrodesis, interphalangeal joints, with or without internal fixation ","code_information":[{"code":"360","type":"RC"},{"code":"C7506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Repair of pulmonary artery arborization anomalies by unifocalization; without cardiopulmonary bypass ","code_information":[{"code":"33925","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Lithotripsy, extracorporeal shock wave ","code_information":[{"code":"50590","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Nephrology (chronic kidney disease), carboxymethyllysine, methylglyoxal hydroimidazolone, and carboxyethyl lysine by liquid chromatography with tandem mass spectrometry and HbA1c and estimated glomeru ","code_information":[{"code":"0384U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":750.000,"maximum":900.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":765.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":900.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":765.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":900.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":750.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":772.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":750.000,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of femur; with allograft ","code_information":[{"code":"27356","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy ","code_information":[{"code":"367","type":"RC"},{"code":"48145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) ","code_information":[{"code":"320","type":"RC"},{"code":"70336","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":310.320,"maximum":377.360,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":310.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":351.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":310.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":377.360,"methodology":"fee schedule"}]}]},{"description":"Excision of vaginal septum ","code_information":[{"code":"490","type":"RC"},{"code":"57130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, sacroiliac joints; 3 or more views ","code_information":[{"code":"324","type":"RC"},{"code":"72202","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":15.990,"maximum":19.450,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.450,"methodology":"fee schedule"}]}]},{"description":"Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) ","code_information":[{"code":"320","type":"RC"},{"code":"77605","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":1502.450,"maximum":1827.020,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1502.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1704.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1502.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1827.020,"methodology":"fee schedule"}]}]},{"description":"Injection, porfimer sodium, 75 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J9600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":39976.890,"maximum":39976.890,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":39976.890,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic ","code_information":[{"code":"63016","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, wrist; complete, minimum of 3 views ","code_information":[{"code":"323","type":"RC"},{"code":"73110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":45.000,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":68.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":77.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":68.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":83.050,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":45.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Excision of chest wall tumor including rib(s) ","code_information":[{"code":"21601","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach ","code_information":[{"code":"21296","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8193.780,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vaginoplasty for intersex state ","code_information":[{"code":"361","type":"RC"},{"code":"57335","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral ","code_information":[{"code":"31574","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws ","code_information":[{"code":"27506","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of ocular implant ","code_information":[{"code":"367","type":"RC"},{"code":"65175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in additi ","code_information":[{"code":"19284","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique ","code_information":[{"code":"310","type":"RC"},{"code":"87481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":36.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.140,"methodology":"fee schedule"}]}]},{"description":"Cardiology, ceramides by liquid chromatography-tandem mass spectrometry, plasma, quantitative report with risk score for major cardiovascular events ","code_information":[{"code":"0119U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":83.760,"maximum":86.270,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":83.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":86.270,"methodology":"fee schedule"}]}]},{"description":"Pyelotomy; complicated (eg, secondary operation, congenital kidney abnormality) ","code_information":[{"code":"50135","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Partial craniectomy, channel creation, and tunneling of electrode for sub-scalp implantation of an electrode array, receiver, and telemetry unit for continuous bilateral electroencephalography monitor ","code_information":[{"code":"0956T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4613.000,"maximum":25200.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25200.000,"methodology":"case rate"}]}]},{"description":"Bypass graft, with other than vein; aortoiliac ","code_information":[{"code":"35637","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1 ","code_information":[{"code":"305","type":"RC"},{"code":"81419","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2448.560,"maximum":2938.270,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2497.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2938.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2497.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2938.270,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2448.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2522.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2448.560,"methodology":"fee schedule"}]}]},{"description":"Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not ","code_information":[{"code":"300","type":"RC"},{"code":"G0481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":156.590,"maximum":187.910,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":159.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":187.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":159.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":187.910,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":156.590,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":161.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":156.590,"methodology":"fee schedule"}]}]},{"description":"Excision of mucosa of vestibule of mouth as donor graft ","code_information":[{"code":"40818","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, image-guided navigation (List separately in addition to code for primary procedureºs») ","code_information":[{"code":"31627","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular) ","code_information":[{"code":"361","type":"RC"},{"code":"64400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Drainage of lymph node abscess or lymphadenitis; 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Western Blot, with interpretation and report, blood or other body fluid ","code_information":[{"code":"310","type":"RC"},{"code":"84181","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.030,"maximum":17.540,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.030,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.540,"methodology":"fee schedule"}]}]},{"description":"Antibody; Trichinella ","code_information":[{"code":"305","type":"RC"},{"code":"86784","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.560,"maximum":15.070,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.070,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.560,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuve ","code_information":[{"code":"37272","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve ","code_information":[{"code":"499","type":"RC"},{"code":"64405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Bypass graft, with vein; carotid-contralateral carotid ","code_information":[{"code":"35509","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) ","code_information":[{"code":"43265","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision ","code_information":[{"code":"367","type":"RC"},{"code":"57522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiopharmaceutical therapy, by intra-articular administration ","code_information":[{"code":"349","type":"RC"},{"code":"79440","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":63.880,"maximum":73.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":63.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":72.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":63.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":73.630,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D1687A","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3216.000,"maximum":3216.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3216.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visc ","code_information":[{"code":"34845","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11794.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Hepatobiliary system imaging, including gallbladder when present; ","code_information":[{"code":"352","type":"RC"},{"code":"78226","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment ","code_information":[{"code":"351","type":"RC"},{"code":"77085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Daratumumab, hyaluronidas ","code_information":[{"code":"09378","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":53.410,"maximum":53.410,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":53.410,"methodology":"fee schedule"}]}]},{"description":"Delay of flap or sectioning of flap (division and inset); at trunk ","code_information":[{"code":"15600","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater ","code_information":[{"code":"22903","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Collection of venous blood by venipuncture ","code_information":[{"code":"314","type":"RC"},{"code":"36415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.340,"maximum":9.620,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.340,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.620,"methodology":"fee schedule"}]}]},{"description":"Insertion, nasal septal prosthesis (button) ","code_information":[{"code":"30220","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Frozen blood, each unit; thawing ","code_information":[{"code":"300","type":"RC"},{"code":"86931","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":291.260,"maximum":349.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":349.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":349.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.260,"methodology":"fee schedule"}]}]},{"description":"Removal of tongs or halo applied by another individual ","code_information":[{"code":"20665","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. 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multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State 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"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1325.360,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy ","code_information":[{"code":"27151","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Venography, adrenal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"349","type":"RC"},{"code":"75840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3241.930,"maximum":3241.930,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3241.930,"methodology":"fee schedule"}]}]},{"description":"Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure) ","code_information":[{"code":"32501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted fetal invasive procedure, including ultrasound guidance, when performed ","code_information":[{"code":"59897","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":505.880,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":516.420,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":505.880,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis ","code_information":[{"code":"43334","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with optical endomicroscopy ","code_information":[{"code":"43252","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; 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M > 38.75 & M < 49.15 ","code_information":[{"code":"118","type":"RC"},{"code":"A2002","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":16226.860,"maximum":18011.820,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":17200.480,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":16226.860,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":18011.820,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":17038.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16389.130,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":16389.130,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":16389.130,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":16226.860,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":18011.820,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":18011.820,"methodology":"fee schedule"}]}]},{"description":"Critical care, evaluation and management of the critically ill or critically injured patient; 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"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 8+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4500.000,"methodology":"per diem","additional_payer_notes":"Days 6+. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy ","code_information":[{"code":"49659","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code fo ","code_information":[{"code":"481","type":"RC"},{"code":"57465","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); ","code_information":[{"code":"25120","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u. 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) ","code_information":[{"code":"341","type":"RC"},{"code":"74181","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10391.800,"maximum":12640.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11788.400,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12640.500,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC ","code_information":[{"code":"923","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2600.560,"maximum":2815.030,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":2815.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":2600.560,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"152","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Nerve repair; with nerve allograft, each nerve, first strand (cable) ","code_information":[{"code":"490","type":"RC"},{"code":"64912","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Insertion of central venous catheter through central venous occlusion via inferior and superior approaches (e.g., inside-out technique), including imaging guidance ","code_information":[{"code":"750","type":"RC"},{"code":"C9780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4613.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Osteotomy, humerus, with or without internal fixation ","code_information":[{"code":"24400","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (inclu ","code_information":[{"code":"21184","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy, unilateral or bilateral ","code_information":[{"code":"320","type":"RC"},{"code":"76513","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":83.260,"maximum":109.530,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":83.260,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair ","code_information":[{"code":"11450","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) ","code_information":[{"code":"82952","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3.920,"maximum":4.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.920,"methodology":"fee schedule"}]}]},{"description":"Ablation, irreversible electroporation, prostate, 1 or more tumors, including imaging guidance, percutaneous ","code_information":[{"code":"361","type":"RC"},{"code":"55877","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents) ","code_information":[{"code":"87184","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7.480,"maximum":8.980,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.480,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, nerve(s) and accompanying structures throughout their entire anatomic course in one extremity, comprehensive, including real-time cine imaging with image documentation, per extremity ","code_information":[{"code":"611","type":"RC"},{"code":"76883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Cocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"Q4264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"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":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of non-biodegradable drug delivery implants, 4 or more (services for subdermal rod implant) ","code_information":[{"code":"480","type":"RC"},{"code":"G0516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5947.170,"maximum":7234.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"}]}]},{"description":"Fibrinogen; activity ","code_information":[{"code":"85384","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9.720,"maximum":11.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11.660,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.720,"methodology":"fee schedule"}]}]},{"description":"Rabies vaccine, im ","code_information":[{"code":"9139","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":319.750,"maximum":335.740,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":322.950,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":329.340,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":335.740,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":319.750,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":335.740,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":335.740,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":322.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":322.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":322.950,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":319.750,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":319.750,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":335.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":326.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":319.750,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":319.750,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":326.140,"methodology":"fee schedule"}]}]},{"description":"Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study ","code_information":[{"code":"616","type":"RC"},{"code":"76828","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant ","code_information":[{"code":"319","type":"RC"},{"code":"81258","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":375.250,"maximum":386.510,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":375.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":386.510,"methodology":"fee schedule"}]}]},{"description":"Intracavitary radiation source application; simple ","code_information":[{"code":"77761","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":1454.690,"maximum":1484.990,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1484.990,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1454.690,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm ","code_information":[{"code":"23075","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Venipuncture, cutdown; younger than age 1 year ","code_information":[{"code":"36420","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair sinus of Valsalva fistula, with cardiopulmonary bypass; ","code_information":[{"code":"33702","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, fam-trastuzumab deruxtecan-nxki, 1 mg 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Laryngeal reinnervation by neuromuscular pedicle ","code_information":[{"code":"31590","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia ","code_information":[{"code":"480","type":"RC"},{"code":"69421","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy, radius; distal third ","code_information":[{"code":"25350","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion ","code_information":[{"code":"61798","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair ","code_information":[{"code":"27557","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and mo ","code_information":[{"code":"322","type":"RC"},{"code":"75574","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":170.600,"maximum":207.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":170.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":193.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":170.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":207.460,"methodology":"fee schedule"}]}]},{"description":"Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation ","code_information":[{"code":"490","type":"RC"},{"code":"68816","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Grafix duo, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"891","type":"RC"},{"code":"Q4392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical therapy, by intra-articular administration ","code_information":[{"code":"611","type":"RC"},{"code":"79440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":230.850,"maximum":230.850,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":230.850,"methodology":"fee schedule"}]}]},{"description":"Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacra ","code_information":[{"code":"22512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":4950.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene path ","code_information":[{"code":"0262U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3200.000,"maximum":3296.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3200.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3296.000,"methodology":"fee schedule"}]}]},{"description":"Manipulation of spine requiring anesthesia, any region ","code_information":[{"code":"22505","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hospital outpatient clinic visit for assessment and management of a patient ","code_information":[{"code":"760","type":"RC"},{"code":"G0463","type":"HCPCS"}],"standard_charges":[{"modifiers":"25","modifiers_description":"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service","setting":"outpatient","minimum":4060.000,"maximum":4060.000,"payers_information":[{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4060.000,"methodology":"case rate"}]}]},{"description":"Revision of colostomy; with repair of paracolostomy hernia (separate procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"44346","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"IDH1 (isocitrate dehydrogenase 1 ºNADP+», soluble) (eg, glioma), common variants (eg, R132H, R132C) ","code_information":[{"code":"311","type":"RC"},{"code":"81120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.250,"maximum":199.050,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":193.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":199.050,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene ","code_information":[{"code":"0112U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":356.130,"maximum":366.810,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":356.130,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":366.810,"methodology":"fee schedule"}]}]},{"description":"Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) ","code_information":[{"code":"312","type":"RC"},{"code":"88283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":68.600,"maximum":82.320,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":69.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":82.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":69.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":82.320,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":68.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":70.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":68.600,"methodology":"fee schedule"}]}]},{"description":"Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection ","code_information":[{"code":"51050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":11562.490,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":11562.490,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":11326.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, dexrazoxane hydrochloride, per 250 mg ","code_information":[{"code":"J1190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":36.620,"maximum":207.630,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":21.58,"standard_charge_algorithm":"Reimbursement will be 21.58% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":126.880,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":36.620,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":207.630,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":78.530,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":203.400,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation ","code_information":[{"code":"27842","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tonsillectomy, primary or secondary; age 12 or over ","code_information":[{"code":"42826","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) ","code_information":[{"code":"81235","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":324.580,"maximum":389.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":331.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":389.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":331.070,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":389.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":334.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":324.580,"methodology":"fee schedule"}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube ","code_information":[{"code":"362","type":"RC"},{"code":"44373","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) ","code_information":[{"code":"23472","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":39422.800,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":36765.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39422.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21676.630,"methodology":"fee schedule","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":28140.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"320","type":"RC"},{"code":"72133","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":222.970,"maximum":271.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":222.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":252.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":222.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":271.130,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (include ","code_information":[{"code":"33958","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation; external carotid artery ","code_information":[{"code":"37600","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial dilation or closed reduction of fracture ","code_information":[{"code":"31630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":9195.060,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":9195.060,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":9007.400,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor, proximal humerus ","code_information":[{"code":"23220","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, spine, cervical; 2 or 3 views ","code_information":[{"code":"402","type":"RC"},{"code":"72040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method ","code_information":[{"code":"30903","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Hepatitis B core antibody (HBcAb); total ","code_information":[{"code":"311","type":"RC"},{"code":"86704","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.050,"maximum":12.410,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.410,"methodology":"fee schedule"}]}]},{"description":"Transposition and/or reimplantation; subclavian to carotid artery ","code_information":[{"code":"35694","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); toe(s), each ","code_information":[{"code":"28092","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid processºes»); with manipulation ","code_information":[{"code":"24675","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Neck/Spine","code_information":[{"code":"22841","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13504.100,"maximum":16426.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15318.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16426.200,"methodology":"case rate"}]}]},{"description":"Burr hole(s) or trephine, infratentorial, unilateral or bilateral ","code_information":[{"code":"61253","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJ MULT TRAUMA NO BRAIN OR SPINAL CORD INJURY; M ","code_information":[{"code":"148","type":"RC"},{"code":"C1702","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20748.290,"maximum":23030.600,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21993.180,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20748.290,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":23030.600,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":21785.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20955.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20955.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20955.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":20748.290,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":23030.600,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":23030.600,"methodology":"fee schedule"}]}]},{"description":"Testicular imaging with vascular flow ","code_information":[{"code":"320","type":"RC"},{"code":"78761","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":218.470,"maximum":413.880,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":218.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed ","code_information":[{"code":"409","type":"RC"},{"code":"77778","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":714.620,"maximum":714.620,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":714.620,"methodology":"fee schedule"}]}]},{"description":"Incision, anal septum (infant) ","code_information":[{"code":"46070","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Riboflavin (Vitamin B-2) ","code_information":[{"code":"312","type":"RC"},{"code":"84252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.240,"maximum":20.850,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.240,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.850,"methodology":"fee schedule"}]}]},{"description":"Vermilionectomy (lip shave), with mucosal advancement ","code_information":[{"code":"40500","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, anesthetic agent; sphenopalatine ganglion ","code_information":[{"code":"490","type":"RC"},{"code":"64505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation ","code_information":[{"code":"20802","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Glucagon tolerance panel; for insulinoma This panel must include the following: Glucose (82947 x 3) Insulin (83525 x 3) ","code_information":[{"code":"311","type":"RC"},{"code":"80422","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":46.070,"maximum":47.450,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":46.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":47.450,"methodology":"fee schedule"}]}]},{"description":"Excision of cervical stump, abdominal approach; with pelvic floor repair ","code_information":[{"code":"57545","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain ","code_information":[{"code":"305","type":"RC"},{"code":"81170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":300.000,"maximum":360.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":306.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":360.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":306.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":360.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":300.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":309.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":300.000,"methodology":"fee schedule"}]}]},{"description":"Liver and spleen imaging; static only ","code_information":[{"code":"329","type":"RC"},{"code":"78215","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Pneumocystis jirovecii, amplified probe technique ","code_information":[{"code":"303","type":"RC"},{"code":"87594","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":42.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, lower extremity; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":38190.000,"methodology":"case rate"}]}]},{"description":"Carpectomy; 1 bone ","code_information":[{"code":"25210","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reduction of overcorrection of ptosis ","code_information":[{"code":"67909","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Antibody; encephalitis, St. Louis ","code_information":[{"code":"309","type":"RC"},{"code":"86653","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.190,"maximum":15.830,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.830,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.190,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.590,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.190,"methodology":"fee schedule"}]}]},{"description":"Application of multi-layer compression system; upper arm, forearm, hand, and fingers ","code_information":[{"code":"29584","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); single tendon ","code_information":[{"code":"27396","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Urine pregnancy test, by visual color comparison methods ","code_information":[{"code":"302","type":"RC"},{"code":"81025","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.610,"maximum":10.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10.330,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.610,"methodology":"fee schedule"}]}]},{"description":"Appendectomy; ","code_information":[{"code":"44950","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system ","code_information":[{"code":"33262","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":18312.220,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":18312.220,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":3850.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":17938.500,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":3850.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Introduction of catheter, right heart or main pulmonary artery ","code_information":[{"code":"36013","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra ","code_information":[{"code":"53000","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Mucoprotein, blood (seromucoid) (medical necessity procedure) ","code_information":[{"code":"314","type":"RC"},{"code":"P2038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.950,"maximum":5.100,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.100,"methodology":"fee schedule"}]}]},{"description":"Mitochondrial antibody (eg, M2), each ","code_information":[{"code":"305","type":"RC"},{"code":"86381","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.450,"maximum":30.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":30.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":30.540,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":26.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.450,"methodology":"fee schedule"}]}]},{"description":"Coccygectomy, primary ","code_information":[{"code":"27080","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous ","code_information":[{"code":"38206","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4208.210,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4208.210,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4122.330,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"C-reactive protein; high sensitivity (hsCRP) ","code_information":[{"code":"86141","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12.950,"maximum":15.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.950,"methodology":"fee schedule"}]}]},{"description":"Oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer ","code_information":[{"code":"0153U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3159.420,"maximum":3791.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3222.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3791.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3222.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3791.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3159.420,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3254.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3159.420,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; 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with manual screening and rescreening under physician supervision ","code_information":[{"code":"319","type":"RC"},{"code":"88165","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.220,"maximum":50.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.660,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":42.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":43.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":42.220,"methodology":"fee schedule"}]}]},{"description":"Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm ","code_information":[{"code":"14301","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed without concurrent CT or CT angiography of the same anatomy ","code_information":[{"code":"400","type":"RC"},{"code":"70473","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":312.340,"maximum":379.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":312.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":354.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":312.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":379.820,"methodology":"fee schedule"}]}]},{"description":"Drainage of lymph node abscess or lymphadenitis; simple ","code_information":[{"code":"369","type":"RC"},{"code":"38300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D194J9","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17085.000,"maximum":17085.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17085.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Fetal shunt placement, including ultrasound guidance ","code_information":[{"code":"499","type":"RC"},{"code":"59076","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation ","code_information":[{"code":"616","type":"RC"},{"code":"74470","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":564.750,"maximum":564.750,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":564.750,"methodology":"fee schedule"}]}]},{"description":"Tonsillectomy, primary or secondary; age 12 or over ","code_information":[{"code":"367","type":"RC"},{"code":"42826","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"305","type":"RC"},{"code":"87320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.000,"maximum":18.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.450,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.000,"methodology":"fee schedule"}]}]},{"description":"Tyrosinemia typr I monitoring by patient-collected blood card sample, quantitative measurement of tyrosine, phenylalanine, methionine, succinylacetone, nitisinone, liquid chromatography with tandem ma ","code_information":[{"code":"0383U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":52.050,"maximum":62.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":53.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":62.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":53.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":62.460,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":52.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":53.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":52.050,"methodology":"fee schedule"}]}]},{"description":"SURGICAL TREATMENT OF ECTOPIC PREGNANCY; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance angiography, neck; 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smears with interpretation ","code_information":[{"code":"319","type":"RC"},{"code":"88104","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":33.840,"maximum":40.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":34.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":40.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":34.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":40.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":33.840,"methodology":"fee schedule"}]}]},{"description":"Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROSI), and KRAS G12C and PL-L1, if performed, formalin-fixed ","code_information":[{"code":"0414U","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":706.250,"maximum":727.440,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":706.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":727.440,"methodology":"fee schedule"}]}]},{"description":"Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pu ","code_information":[{"code":"0495T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation ","code_information":[{"code":"24582","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION, NON-LOWER EXTREMITY; M > 36.35 ","code_information":[{"code":"158","type":"RC"},{"code":"B1101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":21784.010,"maximum":24180.250,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":23091.050,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":21784.010,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":24180.250,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":22873.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22001.850,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":22001.850,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":22001.850,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":21784.010,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":24180.250,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":24180.250,"methodology":"fee schedule"}]}]},{"description":"Immune complex assay ","code_information":[{"code":"305","type":"RC"},{"code":"86332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.370,"maximum":29.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":24.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":29.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":24.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":29.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":24.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":25.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24.370,"methodology":"fee schedule"}]}]},{"description":"REPAIR UMBILICAL HERNIA, YOUNGER THAN AGE 5 YEARS; REDUCIBLE ","code_information":[{"code":"49580","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"342","type":"RC"},{"code":"74220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Urethrocystography, voiding, radiological supervision and interpretation ","code_information":[{"code":"74455","type":"CPT"},{"code":"801958","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":169.870,"maximum":169.870,"gross_charge":1525.75,"discounted_cash":1525.75,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":169.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":169.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":169.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":169.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":169.870,"methodology":"fee schedule"}]}]},{"description":"Revision of total hip arthroplasty; 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count 15-20 cells, 2 karyotypes, with banding ","code_information":[{"code":"319","type":"RC"},{"code":"88262","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":125.490,"maximum":150.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":128.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":150.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":128.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":150.590,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":125.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":129.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":125.490,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Coronary artery bypass, vein only; 4 coronary venous grafts ","code_information":[{"code":"33513","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descendi ","code_information":[{"code":"361","type":"RC"},{"code":"44407","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tri-membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"636","type":"RC"},{"code":"Q4344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete ","code_information":[{"code":"321","type":"RC"},{"code":"76770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":121.000,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":121.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg ","code_information":[{"code":"636","type":"RC"},{"code":"Q5111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":267.280,"maximum":267.280,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":267.280,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater ","code_information":[{"code":"23071","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch ","code_information":[{"code":"69610","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping ","code_information":[{"code":"0264U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1263.530,"maximum":1516.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1288.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1516.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1288.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1516.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1263.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1301.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1263.530,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration ","code_information":[{"code":"490","type":"RC"},{"code":"52250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":25139.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23445.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25139.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11055.000,"methodology":"case rate"}]}]},{"description":"Insertion of ventricular assist device; extracorporeal, biventricular ","code_information":[{"code":"33976","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biopsy of liver, needle; percutaneous ","code_information":[{"code":"47000","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chemiluminescent assay ","code_information":[{"code":"300","type":"RC"},{"code":"82397","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.120,"maximum":16.940,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.120,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.120,"methodology":"fee schedule"}]}]},{"description":" Other Therapeutic Services Athletic Training  ","code_information":[{"code":"951","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Unlisted cardiovascular service or procedure ","code_information":[{"code":"637810","type":"CDM"},{"code":"93799","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":393.460,"maximum":401.650,"gross_charge":8762.00,"discounted_cash":8762.00,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":401.650,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":393.460,"methodology":"fee schedule"}]}]},{"description":"Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance ","code_information":[{"code":"19281","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Harvest of upper extremity vein, 1 segment, for lower extremity or coronary artery bypass procedure (List separately in addition to code for primary procedure) ","code_information":[{"code":"35500","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS ","code_information":[{"code":"64413","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal ","code_information":[{"code":"0933T","type":"CPT"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"NAP","standard_charge_percentage":55.13,"standard_charge_algorithm":"Reimbursement will be 55.13% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial ","code_information":[{"code":"361","type":"RC"},{"code":"46940","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ligation salivary duct, intraoral ","code_information":[{"code":"361","type":"RC"},{"code":"42665","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Riboflavin (Vitamin B-2) ","code_information":[{"code":"310","type":"RC"},{"code":"84252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.240,"maximum":20.850,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.240,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.850,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip ","code_information":[{"code":"27156","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Technetium tc-99m medronate, diagnostic, per study dose, up to 30 millicuries ","drug_information":{"unit":3.000000000000000e+001,"type":"UN"},"code_information":[{"code":"343","type":"RC"},{"code":"807313","type":"CDM"},{"code":"A9503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":106.360,"maximum":106.360,"gross_charge":315.00,"discounted_cash":315.00,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":106.360,"methodology":"fee schedule"}]}]},{"description":"Tracheostomy, planned (separate procedure); younger than 2 years ","code_information":[{"code":"31601","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Glucagon tolerance panel; for pheochromocytoma This panel must include the following: Catecholamines, fractionated (82384 x 2) ","code_information":[{"code":"305","type":"RC"},{"code":"80424","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":50.500,"maximum":60.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":51.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":60.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":51.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":60.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":50.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":52.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":50.500,"methodology":"fee schedule"}]}]},{"description":"Infectious disease (bacterial), quantitative antimicrobial susceptibility reported as phenotypic minimum inhibitory concentration (MIC)\u001a??based antimicrobial susceptibility for each organisms identifi ","code_information":[{"code":"0311U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.080,"maximum":9.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.080,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.320,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.080,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, salivary glands or ducts ","code_information":[{"code":"360","type":"RC"},{"code":"42699","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiation treatment delivery, superficial and/or ortho voltage, per day ","code_information":[{"code":"320","type":"RC"},{"code":"77401","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.120,"maximum":112.780,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":44.120,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":112.780,"methodology":"fee schedule"}]}]},{"description":" Continuous Cycling Peritoneal Dialysis - Outpatient or Home - Maintenance - 100%  ","code_information":[{"code":"854","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":251.000,"maximum":1838.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1511.360,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1714.480,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1511.360,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1838.410,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":251.000,"methodology":"case rate"}]}]},{"description":"HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC ","code_information":[{"code":"522","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13849.420,"maximum":14991.640,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":14991.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":13849.420,"methodology":"fee schedule"}]}]},{"description":"Treatment of closed elbow dislocation; 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without manipulation ","code_information":[{"code":"25530","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Pathology clinical consultation; for a moderately complex clinical problem, with review of patient's history and medical records and moderate level of medical decision making When using time for code ","code_information":[{"code":"80504","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":47.050,"maximum":439.900,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":48.440,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":47.050,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":439.900,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":430.920,"methodology":"fee schedule"}]}]},{"description":"AICD LEAD PROCEDURES ","code_information":[{"code":"265","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21172.410,"maximum":22918.590,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":22918.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":21172.410,"methodology":"fee schedule"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical ","code_information":[{"code":"362","type":"RC"},{"code":"63285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands ","code_information":[{"code":"0490T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7234.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"PMS2 (postmeiotic segregation increased 2 ºS. cerevisiae») (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"314","type":"RC"},{"code":"81319","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":203.500,"maximum":209.610,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":203.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":209.610,"methodology":"fee schedule"}]}]},{"description":"Scleral reinforcement (separate procedure); with graft ","code_information":[{"code":"67255","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biopsy, prostate, transrectal, MRI-ultrasound-fusion guided, targeted lesion(s) only, first targeted lesion ","code_information":[{"code":"55711","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urine pregnancy test, by visual color comparison methods ","code_information":[{"code":"314","type":"RC"},{"code":"81025","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.610,"maximum":8.870,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.870,"methodology":"fee schedule"}]}]},{"description":"Ferritin ","code_information":[{"code":"306","type":"RC"},{"code":"82728","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.630,"maximum":16.360,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.360,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.630,"methodology":"fee schedule"}]}]},{"description":"Exc biopsy of saliv glands ","code_information":[{"code":"369","type":"RC"},{"code":"D7284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; 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","code_information":[{"code":"48000","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation ","code_information":[{"code":"499","type":"RC"},{"code":"50384","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological su ","code_information":[{"code":"36228","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disea ","code_information":[{"code":"306","type":"RC"},{"code":"86328","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":45.280,"maximum":54.340,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":46.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":54.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":46.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":54.340,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":45.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":46.640,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":45.280,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, extraocular muscle ","code_information":[{"code":"362","type":"RC"},{"code":"67399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy ","code_information":[{"code":"15953","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Brachytherapy isodose plan; complex (calculationºs» made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) ","code_information":[{"code":"619","type":"RC"},{"code":"77318","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":377.050,"maximum":377.050,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":377.050,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"329","type":"RC"},{"code":"70496","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":312.340,"maximum":379.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":312.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":354.270,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":312.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":379.820,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"833","type":"MS-DRG"},{"code":"O479","type":"ICD"}],"standard_charges":[{"setting":"inpatient","minimum":3015.000,"maximum":3015.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3015.000,"methodology":"per diem"}]}]},{"description":"Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM) ","code_information":[{"code":"305","type":"RC"},{"code":"81354","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1263.530,"maximum":1516.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1288.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1516.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1288.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1516.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1263.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1301.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1263.530,"methodology":"fee schedule"}]}]},{"description":"Treatment of missed abortion, completed surgically; second trimester ","code_information":[{"code":"59821","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level ","code_information":[{"code":"499","type":"RC"},{"code":"63290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Bleeding time ","code_information":[{"code":"85002","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4.820,"maximum":5.780,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.820,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s) ","code_information":[{"code":"31545","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Free osteocutaneous flap with microvascular anastomosis; great toe with web space ","code_information":[{"code":"20973","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J9201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.920,"maximum":5.920,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.920,"methodology":"fee schedule"}]}]},{"description":"Deligation of ureter ","code_information":[{"code":"50940","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to cod ","code_information":[{"code":"22208","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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 lesion of pancreas (eg, cyst, adenoma) ","code_information":[{"code":"362","type":"RC"},{"code":"48120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure ","code_information":[{"code":"481","type":"RC"},{"code":"52442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"SHOULDER AND ELBOW JOINT REPLACEMENT ","code_information":[{"code":"3223","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15772.020,"maximum":16087.460,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":15772.020,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":16087.460,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":15772.020,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":15772.020,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus ","code_information":[{"code":"31267","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion ","code_information":[{"code":"11102","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, eye, for detection of foreign body ","code_information":[{"code":"322","type":"RC"},{"code":"70030","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":38.680,"maximum":47.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":38.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":43.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":38.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":47.030,"methodology":"fee schedule"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3719.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1671.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3719.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"PENIS PROCEDURES WITH CC/MCC ","code_information":[{"code":"709","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13617.460,"maximum":14740.550,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":14740.550,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":13617.460,"methodology":"fee schedule"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"126","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1094.310,"maximum":1214.680,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1159.960,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1094.310,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1094.310,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1214.680,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1214.680,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Viscosity ","code_information":[{"code":"319","type":"RC"},{"code":"85810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.670,"maximum":12.020,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.670,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.020,"methodology":"fee schedule"}]}]},{"description":"Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure) ","code_information":[{"code":"27400","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Doppler velocimetry, fetal; middle cerebral artery ","code_information":[{"code":"611","type":"RC"},{"code":"76821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"203","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Catecholamines; fractionated ","code_information":[{"code":"305","type":"RC"},{"code":"82384","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.250,"maximum":30.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":25.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":30.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":25.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":30.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":25.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":26.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.250,"methodology":"fee schedule"}]}]},{"description":"Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed ","code_information":[{"code":"27540","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection procedure and placement of chain for contrast and/or chain urethrocystography ","code_information":[{"code":"51605","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7365.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"}]}]},{"description":"Repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue ","code_information":[{"code":"490","type":"RC"},{"code":"65285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of neuroma; hand or foot, except digital nerve ","code_information":[{"code":"369","type":"RC"},{"code":"64782","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"BCR/ABL1 (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative ","code_information":[{"code":"0040U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":409.900,"maximum":422.200,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":409.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":422.200,"methodology":"fee schedule"}]}]},{"description":"Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap) ","code_information":[{"code":"15731","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Phenytoin; free ","code_information":[{"code":"309","type":"RC"},{"code":"80186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.760,"maximum":16.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.510,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.170,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.760,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"213","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MINOR BLADDER PROCEDURES WITH CC One Day Stay","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MR safety implant electronics preparation under supervision of physician or other qualified health care professional, including MR-specific programming of pulse generator and/or transmitter to verify ","code_information":[{"code":"320","type":"RC"},{"code":"76018","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":129.810,"maximum":157.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":129.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":147.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":129.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":157.860,"methodology":"fee schedule"}]}]},{"description":"Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) ","code_information":[{"code":"22840","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; first 480 sq cm or less ","code_information":[{"code":"15015","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA), Bartonella henselae and Bartonella quintana, droplet digital PCR (ddPCR); following liquid enrichment ","code_information":[{"code":"0302U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":361.370,"maximum":433.640,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":368.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":433.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":368.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":433.640,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":361.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":372.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":361.370,"methodology":"fee schedule"}]}]},{"description":"Injection procedure for intraoperative pancreatography (List separately in addition to code for primary procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"48400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cholecystoenterostomy; Roux-en-Y ","code_information":[{"code":"47740","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"TRANSIENT ISCHEMIA ","code_information":[{"code":"0474","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8175.700,"maximum":8339.210,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":8175.700,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":8339.210,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":8175.700,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":8175.700,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female ","code_information":[{"code":"481","type":"RC"},{"code":"52281","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Arterial puncture, withdrawal of blood for diagnosis ","code_information":[{"code":"360","type":"RC"},{"code":"36600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling ","code_information":[{"code":"367","type":"RC"},{"code":"46947","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of double outlet right ventricle with intraventricular tunnel repair; ","code_information":[{"code":"33611","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Myringotomy including aspiration and/or eustachian tube inflation ","code_information":[{"code":"361","type":"RC"},{"code":"69420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Resection prosthesis, maxillary implant/abutment supported removable prosthesis for edentulous arch ","code_information":[{"code":"481","type":"RC"},{"code":"D5942","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences ","code_information":[{"code":"329","type":"RC"},{"code":"70553","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":162.120,"maximum":197.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":162.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":183.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":162.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":197.140,"methodology":"fee schedule"}]}]},{"description":"Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery ","code_information":[{"code":"361","type":"RC"},{"code":"63610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) ","code_information":[{"code":"27105","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"116","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1019.840,"maximum":1132.020,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1081.030,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1132.020,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1132.020,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches ","code_information":[{"code":"21344","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Bcg live intravesical instillation, 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J9030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.410,"maximum":5.410,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.410,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"409","type":"RC"},{"code":"72130","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":225.120,"maximum":273.750,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":225.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":255.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":225.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":273.750,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; with biopsy, single or multiple ","code_information":[{"code":"369","type":"RC"},{"code":"45331","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Bypass graft, with other than vein; ilioiliac ","code_information":[{"code":"35663","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hereditary pan-cancer (eg, Hereditary sarcomas, hereditary endocrine tumors, hereditary cutaneous melanoma),genomic sequence analysis panel of 88 genes with 20 duplications/deletions using nextgen ","code_information":[{"code":"0474U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1303.950,"maximum":1343.070,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1303.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1343.070,"methodology":"fee schedule"}]}]},{"description":"Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in addition to code for primary procedure) ","code_information":[{"code":"33530","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence ","code_information":[{"code":"304","type":"RC"},{"code":"81238","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":600.000,"maximum":720.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":612.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":720.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":612.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":720.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":600.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":618.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":600.000,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis) ","code_information":[{"code":"35636","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OSTEOARTHRITIS; M=39-47 ","code_information":[{"code":"148","type":"RC"},{"code":"A1204","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":22711.810,"maximum":25210.110,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":24074.520,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":22711.810,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":25210.110,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":23847.400,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22938.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":22938.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":22938.930,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":22711.810,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":25210.110,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":25210.110,"methodology":"fee schedule"}]}]},{"description":"Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation and peri-operative interrogation and programming; complete system (incl ","code_information":[{"code":"360","type":"RC"},{"code":"C9750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HLA typing; lymphocyte culture, mixed (MLC) ","code_information":[{"code":"86821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.310,"maximum":43.870,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":36.930,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":32.900,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":38.390,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":37.660,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":37.290,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":38.390,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":36.560,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":38.390,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":38.390,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":43.870,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":36.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":36.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":36.930,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":36.560,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":31.310,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":36.560,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":38.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":37.290,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":36.560,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":36.560,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":37.290,"methodology":"fee schedule"}]}]},{"description":"Borrelia burgdoferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG ","code_information":[{"code":"0042U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.210,"maximum":17.730,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.210,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.730,"methodology":"fee schedule"}]}]},{"description":"Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) ","code_information":[{"code":"97116","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.380,"maximum":29.020,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","median_amount":50.570,"10th_percentile":50.570,"90th_percentile":50.570,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","median_amount":50.570,"10th_percentile":50.570,"90th_percentile":50.570,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","median_amount":50.570,"10th_percentile":50.570,"90th_percentile":50.570,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","median_amount":50.570,"10th_percentile":50.570,"90th_percentile":50.570,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":21.58,"standard_charge_algorithm":"Reimbursement will be 21.58% of billable gross charges.","median_amount":39.180,"10th_percentile":39.180,"90th_percentile":39.180,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":28.470,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":27.920,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":26.380,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":29.020,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":28.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":28.190,"methodology":"fee schedule"}]}]},{"description":"Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography ","code_information":[{"code":"369","type":"RC"},{"code":"47620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC ","code_information":[{"code":"138","type":"RC"},{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy ","code_information":[{"code":"369","type":"RC"},{"code":"57155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":25139.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23445.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25139.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11055.000,"methodology":"case rate"}]}]},{"description":"Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I ","code_information":[{"code":"21155","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Biopsy of testis, incisional (separate procedure) ","code_information":[{"code":"54505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8162.410,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8162.410,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7995.830,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card) ","code_information":[{"code":"307","type":"RC"},{"code":"86005","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.970,"maximum":9.560,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.560,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.970,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.970,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D198JA","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3216.000,"maximum":3216.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3216.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm ","code_information":[{"code":"12013","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis ","code_information":[{"code":"43333","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biofeedback training by any modality ","code_information":[{"code":"90901","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.450,"maximum":40.140,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":38.610,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":39.380,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":40.140,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":38.230,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":40.140,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":40.140,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":38.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":38.610,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":38.610,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":38.230,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":35.450,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":38.230,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":40.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":38.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":38.230,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":38.230,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":38.990,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation ","code_information":[{"code":"25680","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"302","type":"RC"},{"code":"87305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.980,"maximum":14.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.380,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.980,"methodology":"fee schedule"}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less ","code_information":[{"code":"11400","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in ","code_information":[{"code":"34713","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed ","code_information":[{"code":"64561","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":46230.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":36765.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39422.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":46230.000,"methodology":"case rate"}]}]},{"description":"Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular ","code_information":[{"code":"27429","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance angiography without contrast, lower extremity ","code_information":[{"code":"618","type":"RC"},{"code":"C8913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":517.790,"maximum":517.790,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid processºes»); with manipulation ","code_information":[{"code":"24675","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs ","code_information":[{"code":"15572","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"45378","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Cranioplasty for skull defect; larger than 5 cm diameter ","code_information":[{"code":"360","type":"RC"},{"code":"62141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cm ","code_information":[{"code":"26115","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) ","code_information":[{"code":"44370","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D194JB","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3216.000,"maximum":3216.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3216.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter) ","code_information":[{"code":"362","type":"RC"},{"code":"51736","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS ","code_information":[{"code":"8902","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5665.050,"maximum":5778.350,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":5665.050,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5778.350,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":5665.050,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":5665.050,"methodology":"fee schedule"}]}]},{"description":"Aspiration and/or injection, thyroid cyst ","code_information":[{"code":"367","type":"RC"},{"code":"60300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"FRACTURES OF FEMUR WITH MCC ","code_information":[{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3719.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1671.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3719.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) ","code_information":[{"code":"619","type":"RC"},{"code":"78016","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheter ","code_information":[{"code":"36254","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) ","code_information":[{"code":"342","type":"RC"},{"code":"78708","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":273.570,"maximum":1101.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":273.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":310.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":273.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":315.330,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":554.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1101.150,"methodology":"fee schedule"}]}]},{"description":"Percutaneous aspiration, spinal cord cyst or syrinx ","code_information":[{"code":"480","type":"RC"},{"code":"62268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERIPH FIELD STIMUL PERM ","code_information":[{"code":"0283T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4337.000,"maximum":13614.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13614.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4337.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulotomy, posterior capsular release, knee ","code_information":[{"code":"27435","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic angiography (CTA), head and neck, with contrast material(s), including noncontrast images, when performed, and image postprocessing ","code_information":[{"code":"322","type":"RC"},{"code":"70471","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":416.950,"maximum":507.020,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":416.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":472.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":416.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":507.020,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"1001","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":992.520,"maximum":992.520,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":992.520,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Open treatment of carpal bone fracture (other than carpal scaphoid ºnavicular»), each bone ","code_information":[{"code":"25645","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Repair blood vessel with graft other than vein; intra-abdominal ","code_information":[{"code":"35281","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Removal of foreign body, deep, thigh region or knee area ","code_information":[{"code":"27372","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional 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; thoracic ","code_information":[{"code":"22101","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Orchiopexy, inguinal or scrotal approach ","code_information":[{"code":"490","type":"RC"},{"code":"54640","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, zoledronic acid, 1 mg ","code_information":[{"code":"J3489","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.940,"maximum":9.230,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":8.470,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":9.230,"methodology":"fee schedule"}]}]},{"description":"Open treatment of craniofacial separation (LeFort III type); 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","code_information":[{"code":"302","type":"RC"},{"code":"811778","type":"CDM"},{"code":"86803","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.270,"maximum":17.120,"gross_charge":158.00,"discounted_cash":158.00,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.120,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.270,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, abdomen, with or without contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"74185","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":408.180,"maximum":496.360,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":408.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":462.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":408.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":496.360,"methodology":"fee schedule"}]}]},{"description":"Smear, primary source with interpretation; 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1-3 ribs ","code_information":[{"code":"21811","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Craniectomy; with excision of tumor or other bone lesion of skull ","code_information":[{"code":"361","type":"RC"},{"code":"61500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Impression and custom preparation; orbital prosthesis ","code_information":[{"code":"21077","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D160KA","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3216.000,"maximum":3216.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3216.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Catheterization, umbilical artery, newborn, for diagnosis or therapy ","code_information":[{"code":"36660","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Suture of major peripheral nerve, arm or leg, except sciatic; including transposition ","code_information":[{"code":"64856","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Babesia microti, amplified probe technique ","code_information":[{"code":"311","type":"RC"},{"code":"87469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":36.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.140,"methodology":"fee schedule"}]}]},{"description":"Excision or destruction of lesion of pharynx, any method ","code_information":[{"code":"42808","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, hip, surgical; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc spac ","code_information":[{"code":"22853","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique ","code_information":[{"code":"302","type":"RC"},{"code":"87650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.050,"maximum":24.060,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.060,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.650,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.050,"methodology":"fee schedule"}]}]},{"description":"Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae ","code_information":[{"code":"481","type":"RC"},{"code":"65865","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"All potassium hydroxide (koh) preparations ","code_information":[{"code":"312","type":"RC"},{"code":"Q0112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.830,"maximum":6.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.000,"methodology":"fee schedule"}]}]},{"description":"Autologous blood or component, collection processing and storage; predeposited ","code_information":[{"code":"307","type":"RC"},{"code":"86890","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.160,"maximum":178.990,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":152.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":178.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":152.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":178.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Antibody; Francisella tularensis ","code_information":[{"code":"305","type":"RC"},{"code":"86668","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.160,"maximum":16.990,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.990,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.160,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.160,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendonºs», muscleºs», nerveºs», other soft-tissue structureºs», or soft-tiss ","code_information":[{"code":"400","type":"RC"},{"code":"76882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Injection, micafungin in sodium (baxter), not therapeutically equivalent to j2248, 1 mg ","code_information":[{"code":"J2246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.580,"maximum":0.620,"payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":0.580,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":0.620,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Parainfluenza virus, each type ","code_information":[{"code":"314","type":"RC"},{"code":"87279","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.430,"maximum":16.920,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.430,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.920,"methodology":"fee schedule"}]}]},{"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":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Neurology (traumatic brain injury), analysis of glial fibrillary acidic protein (GFAP) and ubiquitin carboxylterminal hydrolase L1 (UCHL1), immunoassay, whole blood or plasma, individual components ","code_information":[{"code":"0570U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":260.500,"maximum":312.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":265.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":312.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":265.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":312.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":260.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":268.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":260.500,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"983","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8717.900,"maximum":9436.900,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":9436.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":8717.900,"methodology":"fee schedule"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC ","code_information":[{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9849.000,"maximum":9849.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9849.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"Removal of foreign body, foot; deep ","code_information":[{"code":"28192","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Myocardial imaging, infarct avid, planar; qualitative or quantitative ","code_information":[{"code":"615","type":"RC"},{"code":"78466","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy ","code_information":[{"code":"490","type":"RC"},{"code":"61530","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract format ","code_information":[{"code":"37182","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique ","code_information":[{"code":"45315","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":3026.830,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":3026.830,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":2965.060,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Special teletherapy port plan, particles, hemibody, total body ","code_information":[{"code":"322","type":"RC"},{"code":"77321","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":72.120,"maximum":87.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":72.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":81.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":72.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":87.700,"methodology":"fee schedule"}]}]},{"description":"Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) ","code_information":[{"code":"361","type":"RC"},{"code":"68335","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75741","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":111.880,"maximum":136.050,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":111.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":126.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":111.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":136.050,"methodology":"fee schedule"}]}]},{"description":"Sperm washing for artificial insemination ","code_information":[{"code":"58323","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence ","code_information":[{"code":"301","type":"RC"},{"code":"81307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":676.500,"maximum":696.800,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":676.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":696.800,"methodology":"fee schedule"}]}]},{"description":"Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed) ","code_information":[{"code":"480","type":"RC"},{"code":"64489","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III) ","code_information":[{"code":"47140","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells (eg, for derivatives and markers) ","code_information":[{"code":"309","type":"RC"},{"code":"88272","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.700,"maximum":41.920,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":40.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.920,"methodology":"fee schedule"}]}]},{"description":"Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion ","code_information":[{"code":"67420","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis ","code_information":[{"code":"312","type":"RC"},{"code":"81295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":381.700,"maximum":393.150,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":381.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":393.150,"methodology":"fee schedule"}]}]},{"description":"Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist ","code_information":[{"code":"95807","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1334.310,"maximum":1362.110,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1362.110,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1334.310,"methodology":"fee schedule"}]}]},{"description":"Nerve repair; with nerve allograft, each nerve, first strand (cable) ","code_information":[{"code":"360","type":"RC"},{"code":"64912","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC SPINAL CORD INJURY; M > 30.35 & M < 48.4 ","code_information":[{"code":"118","type":"RC"},{"code":"D0402","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":21774.340,"maximum":24169.520,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":23080.800,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":21774.340,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":24169.520,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":22863.060,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21992.090,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":21992.090,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":21992.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":21774.340,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":24169.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":24169.520,"methodology":"fee schedule"}]}]},{"description":"Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to ","code_information":[{"code":"34820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0278U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":608.170,"maximum":626.420,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":626.420,"methodology":"fee schedule"}]}]},{"description":"Necropsy (autopsy), limited, gross and/or microscopic; single organ ","code_information":[{"code":"314","type":"RC"},{"code":"88037","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":93.510,"maximum":112.210,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":95.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":112.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":95.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":112.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":93.510,"methodology":"fee schedule"}]}]},{"description":"Angiography, extremity, unilateral, radiological supervision and interpretation ","code_information":[{"code":"75710","type":"CPT"},{"code":"806460","type":"CDM"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":7915.080,"maximum":8079.980,"gross_charge":31433.25,"discounted_cash":31433.25,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8079.980,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7915.080,"methodology":"fee schedule"}]}]},{"description":"HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) ","code_information":[{"code":"304","type":"RC"},{"code":"81362","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":375.250,"maximum":450.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":382.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":450.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":382.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":450.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":375.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":386.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":375.250,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast inje ","code_information":[{"code":"36252","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Arthrotomy with synovectomy, hip joint ","code_information":[{"code":"27054","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION  IPF","code_information":[{"code":"144","type":"RC"},{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1051.570,"maximum":1167.240,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1051.570,"methodology":"fee schedule","additional_payer_notes":"Days 5. 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"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1167.240,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"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":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, wrist; 2 views ","code_information":[{"code":"340","type":"RC"},{"code":"73100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Coronary artery bypass, vein only; 6 or more coronary venous grafts ","code_information":[{"code":"33516","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multi ","code_information":[{"code":"15017","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, chest (includes mediastinum), real time with image documentation ","code_information":[{"code":"403","type":"RC"},{"code":"76604","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with rhizotomy; more than 2 segments ","code_information":[{"code":"481","type":"RC"},{"code":"63190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5263.000,"maximum":19440.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC* ","code_information":[{"code":"841","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9248.240,"maximum":10010.980,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":10010.980,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":9248.240,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; metatarsal ","code_information":[{"code":"28173","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closure of laceration, vestibule of mouth; 2.5 cm or less ","code_information":[{"code":"40830","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage ","code_information":[{"code":"46285","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lesion of tongue with closure; posterior one-third ","code_information":[{"code":"41113","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Osteotomy, humerus, with or without internal fixation ","code_information":[{"code":"24400","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Unlisted ultrasound procedure (eg, diagnostic, interventional) ","code_information":[{"code":"402","type":"RC"},{"code":"76999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":182.030,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Neck/Spine","code_information":[{"code":"22841","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13504.100,"maximum":16426.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15318.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16426.200,"methodology":"case rate"}]}]},{"description":"Antipsychotics, not otherwise specified; 1-3 ","code_information":[{"code":"80342","type":"CPT"},{"code":"822878","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":22.350,"maximum":23.010,"gross_charge":241.75,"discounted_cash":241.75,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":23.010,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":22.350,"methodology":"fee schedule"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral ","code_information":[{"code":"35372","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy ","code_information":[{"code":"481","type":"RC"},{"code":"67101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (pild) or placebo-control, performed in an approved coverage with evidence development (ced) clinical trial ","code_information":[{"code":"361","type":"RC"},{"code":"G0276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Amputation, arm through humerus; re-amputation ","code_information":[{"code":"24930","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6271.280,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Closure of ureterocutaneous fistula ","code_information":[{"code":"360","type":"RC"},{"code":"50920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation ","code_information":[{"code":"404","type":"RC"},{"code":"76801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Repair of nasolabial fistula ","code_information":[{"code":"42260","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique ","code_information":[{"code":"400","type":"RC"},{"code":"78468","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":554.420,"maximum":554.420,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":554.420,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, cervical spine; with contrast material ","code_information":[{"code":"618","type":"RC"},{"code":"72126","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":367.840,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"}]}]},{"description":"BURNS; M > 0 ","code_information":[{"code":"B2101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":25327.240,"maximum":26387.930,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":25870.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25327.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":25870.520,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":26387.930,"methodology":"fee schedule"}]}]},{"description":"IV OCT FOR PROC ADDL VESSEL ","code_information":[{"code":"0292T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2028.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transferrin ","code_information":[{"code":"314","type":"RC"},{"code":"84466","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.760,"maximum":13.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.140,"methodology":"fee schedule"}]}]},{"description":"O.R. 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not ","code_information":[{"code":"323","type":"RC"},{"code":"76376","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.870,"maximum":48.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":40.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":45.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":40.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":48.840,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":26.870,"methodology":"fee schedule"}]}]},{"description":"Intra-atrial recording ","code_information":[{"code":"790","type":"RC"},{"code":"93602","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":36180.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7591.060,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8611.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7591.060,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9233.710,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36180.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, cervical; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Unlisted miscellaneous procedure, diagnostic nuclear medicine ","code_information":[{"code":"615","type":"RC"},{"code":"78999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Removal of lens material; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"HLaryngotomy (thyrotomy, laryngofissure); diagnostic ","code_information":[{"code":"31320","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints ","code_information":[{"code":"21470","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Obstetrics (preeclampsia), biochemical assay of placental-growth factor, time-resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score for preeclampsia ","code_information":[{"code":"0243U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":64.410,"maximum":77.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":65.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":77.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":65.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":77.290,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":64.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":66.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":64.410,"methodology":"fee schedule"}]}]},{"description":"Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft) ","code_information":[{"code":"26434","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY One Day Stay","code_information":[{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) ","code_information":[{"code":"400","type":"RC"},{"code":"71555","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":127.260,"maximum":154.760,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":127.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":144.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":127.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":154.760,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, wrist; 2 views ","code_information":[{"code":"321","type":"RC"},{"code":"73100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.430,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":54.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":62.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":54.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":66.690,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":37.430,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, knee, hinge prosthesis (eg, Walldius type) ","code_information":[{"code":"27445","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not ","code_information":[{"code":"321","type":"RC"},{"code":"76376","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.870,"maximum":48.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":40.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":45.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":40.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":48.840,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":26.870,"methodology":"fee schedule"}]}]},{"description":"Fine needle aspiration biopsy, including ultrasound guidance; first lesion ","code_information":[{"code":"10005","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2534.000,"maximum":7234.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Insertion of peritoneal-venous shunt ","code_information":[{"code":"49425","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"COMPLICATIONS OF TREATMENT WITHOUT CC/MCC One Day Stay","code_information":[{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 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","code_information":[{"code":"320","type":"RC"},{"code":"78013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":193.430,"maximum":413.880,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":193.430,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) stu ","code_information":[{"code":"324","type":"RC"},{"code":"74246","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":401.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":214.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":242.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":214.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":260.390,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnor ","code_information":[{"code":"342","type":"RC"},{"code":"76506","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, lumbosacral; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography ","code_information":[{"code":"27369","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS ","code_information":[{"code":"2422","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5150.050,"maximum":5253.050,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":5150.050,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":5253.050,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":5150.050,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":5150.050,"methodology":"fee schedule"}]}]},{"description":"AMPUTATION, LOWER EXTREMITY; M=39-45 ","code_information":[{"code":"128","type":"RC"},{"code":"A1004","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":26658.190,"maximum":29590.590,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":28257.680,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":26658.190,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":29590.590,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":27991.100,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":26924.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":26924.770,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":26924.770,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":26658.190,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":29590.590,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":29590.590,"methodology":"fee schedule"}]}]},{"description":"SPLENIC PROCEDURES WITH MCC ","code_information":[{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4523.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 7+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 7+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 7+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1671.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 7+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4523.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm ","code_information":[{"code":"11602","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infusion, albumin (human), 5%, 50 ml ","code_information":[{"code":"891","type":"RC"},{"code":"P9041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":17.520,"maximum":17.520,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.520,"methodology":"fee schedule"}]}]},{"description":"Repair initial femoral hernia, any age; incarcerated or strangulated ","code_information":[{"code":"367","type":"RC"},{"code":"49553","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motionºs» and/or ejection fractionºs», when performed), single study; ","code_information":[{"code":"322","type":"RC"},{"code":"78459","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.680,"maximum":1344.640,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":84.680,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1344.640,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, posterior technique, atlas-axis (C1-C2) Neck/Spine","code_information":[{"code":"22595","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":13504.100,"maximum":16426.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15318.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13504.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16426.200,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcript ","code_information":[{"code":"303","type":"RC"},{"code":"87505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.290,"maximum":153.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":130.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":153.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":130.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":153.950,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":128.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":132.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":128.290,"methodology":"fee schedule"}]}]},{"description":"Strapping; hand or finger ","code_information":[{"code":"29280","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Resection of lip, more than one-fourth, without reconstruction ","code_information":[{"code":"369","type":"RC"},{"code":"40530","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Xwrap hydro plus, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"892","type":"RC"},{"code":"Q4404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Percutaneous vertebral augmentations, first lumbar and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) us ","code_information":[{"code":"480","type":"RC"},{"code":"C7508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":10052.400,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"}]}]},{"description":"Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous vein patch graft ","code_information":[{"code":"35884","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) ","code_information":[{"code":"27006","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, thorax, diagnostic; without contrast material ","code_information":[{"code":"322","type":"RC"},{"code":"71250","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":134.140,"maximum":163.120,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":134.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":152.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":134.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":163.120,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater ","code_information":[{"code":"24071","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (List separately in addition to code for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"64421","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk ","code_information":[{"code":"36468","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and ","code_information":[{"code":"360","type":"RC"},{"code":"61645","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar; 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by forearm vein transposition ","code_information":[{"code":"36820","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Closure of rectovesical fistula; with colostomy ","code_information":[{"code":"45805","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D1607L","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3216.000,"maximum":3216.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3216.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure) ","code_information":[{"code":"44015","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Procalcitonin (PCT) ","code_information":[{"code":"312","type":"RC"},{"code":"84145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.220,"maximum":28.040,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":28.040,"methodology":"fee schedule"}]}]},{"description":"Hepatology (nonalcoholic fatty liver disease), semiquantitative evaluation of 28 lipid markers by liquid chromatography with tandem mass spectometry, serum, reported as at-risk for nonalcoholic steato ","code_information":[{"code":"0344U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":792.170,"maximum":815.940,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":792.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":815.940,"methodology":"fee schedule"}]}]},{"description":"Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood) ","code_information":[{"code":"310","type":"RC"},{"code":"87102","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.410,"maximum":8.660,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.660,"methodology":"fee schedule"}]}]},{"description":"Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminect ","code_information":[{"code":"62351","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ARTERY TO VEIN SHUNT ","code_information":[{"code":"36145","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Radiologic examination, wrist; 2 views ","code_information":[{"code":"409","type":"RC"},{"code":"73100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":54.840,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":54.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":62.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":54.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":66.690,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate ","code_information":[{"code":"67882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":5889.550,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":5889.550,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":5769.350,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) ","code_information":[{"code":"303","type":"RC"},{"code":"81337","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":185.200,"maximum":222.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":190.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS ","code_information":[{"code":"33988","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Oncology, DNA and RNA by nex-gen sequencing, utilizing FFPE tissue, 437 genes, interpretive report for single nucleotide variants, splicesite variants, inserts/deletions, copy number alterations, gene ","code_information":[{"code":"0391U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3600.000,"maximum":4320.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3672.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4320.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3672.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4320.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3600.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3708.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3600.000,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"610","type":"RC"},{"code":"74175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography without contrast followed by with contrast, upper extremity ","code_information":[{"code":"610","type":"RC"},{"code":"C8936","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":828.270,"maximum":828.270,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); 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"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11788.400,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12640.500,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Osteotomy; metacarpal, each ","code_information":[{"code":"26565","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Subdural implantation of strip electrodes through 1 or more burr or trephine hole(s) for long-term seizure monitoring ","code_information":[{"code":"362","type":"RC"},{"code":"61531","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm ","code_information":[{"code":"17273","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous ","code_information":[{"code":"26040","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Injection, oritavancin (orbactiv), 10 mg ","drug_information":{"unit":4.000000000000000e+002,"type":"ME"},"code_information":[{"code":"904804","type":"CDM"},{"code":"J2407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":27.670,"maximum":73.240,"gross_charge":4337.75,"discounted_cash":4337.75,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":32.410,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":32.550,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":73.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":27.670,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":71.740,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH CC ","code_information":[{"code":"206","type":"RC"},{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Brain imaging, vascular flow only ","code_information":[{"code":"340","type":"RC"},{"code":"78610","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":230.240,"maximum":265.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":230.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":261.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":230.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":265.380,"methodology":"fee schedule"}]}]},{"description":"Thymol turbidity, blood ","code_information":[{"code":"301","type":"RC"},{"code":"P2033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.950,"maximum":5.940,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.950,"methodology":"fee schedule"}]}]},{"description":"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level ","code_information":[{"code":"64491","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automate ","code_information":[{"code":"81000","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4.020,"maximum":4.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.820,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.020,"methodology":"fee schedule"}]}]},{"description":"BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative ","code_information":[{"code":"302","type":"RC"},{"code":"81206","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":163.960,"maximum":196.750,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":167.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":196.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":167.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":196.750,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":163.960,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":168.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":163.960,"methodology":"fee schedule"}]}]},{"description":"Creation of pericardial window or partial resection for drainage ","code_information":[{"code":"33025","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Phospholipid neutralization; platelet ","code_information":[{"code":"307","type":"RC"},{"code":"85597","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.980,"maximum":21.580,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.980,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.980,"methodology":"fee schedule"}]}]},{"description":"Oncology (colorectal and lung), DNA from formalin-fixed paraffin-embedded (FFPE) tissue, next-generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS and TP53), mutation detectio ","code_information":[{"code":"0499U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":597.910,"maximum":717.490,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":609.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":717.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":609.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":717.490,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":597.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":615.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":597.910,"methodology":"fee schedule"}]}]},{"description":"Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bi-iliac prosthesis ","code_information":[{"code":"34831","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Transfusion, intrauterine, fetal ","code_information":[{"code":"360","type":"RC"},{"code":"36460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC One Day Stay","code_information":[{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"56501","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"EXTRACRANIAL PROCEDURES WITHOUT CC/MCC One Day Stay","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Innovamatrix pd, 1 mg ","code_information":[{"code":"344","type":"RC"},{"code":"A2023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":28.100,"maximum":28.100,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":28.100,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level ","code_information":[{"code":"64479","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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 bone (eg, for osteomyelitis or bone abscess); mandible ","code_information":[{"code":"21025","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"ACCESS AV DIAL GRFT FOR PROC ","code_information":[{"code":"360","type":"RC"},{"code":"36148","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2028.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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 up to 100 sq cm; each additional 25 sq ","code_information":[{"code":"15276","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency ","code_information":[{"code":"47370","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19440.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, Flow cytometry); high definition qualitative panel for identification of antibody specificities (eg, i ","code_information":[{"code":"304","type":"RC"},{"code":"86833","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":325.800,"maximum":390.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":332.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":390.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":332.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":390.960,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":325.800,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":335.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":325.800,"methodology":"fee schedule"}]}]},{"description":"Unlisted ultrasound procedure (eg, diagnostic, interventional) ","code_information":[{"code":"615","type":"RC"},{"code":"76999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of ankle dislocation; without anesthesia ","code_information":[{"code":"27840","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views ","code_information":[{"code":"322","type":"RC"},{"code":"73502","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":16.550,"maximum":20.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.130,"methodology":"fee schedule"}]}]},{"description":"Cystourethroplasty with unilateral or bilateral ureteroneocystostomy ","code_information":[{"code":"499","type":"RC"},{"code":"51820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Immunoelectrophoresis; serum ","code_information":[{"code":"310","type":"RC"},{"code":"86320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.920,"maximum":30.820,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":29.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":30.820,"methodology":"fee schedule"}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH ","code_information":[{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13500.000,"maximum":45370.580,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":41623.440,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":17104.470,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":41623.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":41623.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":41623.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":29731.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37299.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42311.910,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":17443.170,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37299.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45370.580,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":21168.900,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":17273.820,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":17273.820,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":20237.330,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":17612.520,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22643.920,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":17612.520,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":16982.940,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":17104.470,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":17104.470,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":17104.470,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":16935.120,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":17612.520,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":19824.330,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":17612.520,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17781.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16579.480,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":16935.120,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":16935.120,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":17273.820,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, carotid, subclavian artery, by neck incision ","code_information":[{"code":"35002","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Guided tissue regeneration - resorbable barrier, per implant ","code_information":[{"code":"369","type":"RC"},{"code":"D6106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection ","code_information":[{"code":"0088U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3159.420,"maximum":3791.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3222.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3791.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3222.610,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3791.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3159.420,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3254.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3159.420,"methodology":"fee schedule"}]}]},{"description":"Removal foreign body, intranasal; office type procedure ","code_information":[{"code":"30300","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple ","code_information":[{"code":"44361","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Targeted genomic sequence analysis panel, solid organ neoplasm, circulating cell-free DNA (cfDNA) analysis from plasma of 521 genes, interrogation for sequence variants, ","code_information":[{"code":"0585U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2919.600,"maximum":3503.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2977.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3503.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2977.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3503.520,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3007.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2919.600,"methodology":"fee schedule"}]}]},{"description":"Injection, valproate sodium, 5 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J3379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.080,"maximum":0.080,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.080,"methodology":"fee schedule"}]}]},{"description":"Repair of wound, extraocular muscle, tendon and/or Tenon's capsule ","code_information":[{"code":"360","type":"RC"},{"code":"65290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of a ","code_information":[{"code":"33965","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance ","code_information":[{"code":"55706","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other p ","code_information":[{"code":"367","type":"RC"},{"code":"49616","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by ","code_information":[{"code":"35011","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces in ","code_information":[{"code":"L0651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1263.350,"maximum":1367.540,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1315.440,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":1341.490,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1367.540,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1302.420,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1367.540,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1367.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1315.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":1315.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":1315.440,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1302.420,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":1263.350,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1302.420,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1367.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1328.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":1302.420,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1302.420,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":1328.470,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with percutaneous transluminal coronary lithotripsy ","code_information":[{"code":"481","type":"RC"},{"code":"C7571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Free muscle or myocutaneous flap with microvascular anastomosis ","code_information":[{"code":"15756","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"135","type":"RC"},{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. 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thoracotomy ","code_information":[{"code":"43328","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, multiples amplified probe technique, vaginal, endocervical, or male urine, each pathogen r ","code_information":[{"code":"0402U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":142.630,"maximum":171.160,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":145.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":171.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":145.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":171.160,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":146.910,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":142.630,"methodology":"fee schedule"}]}]},{"description":"Selective enzymatic debridement, partial-thickness and/or full-thickness burn eschar, requiring anesthesia (ie, general anesthesia, moderate sedation), including patient monitoring, scalp, neck, hands ","code_information":[{"code":"0976T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Removal of tunneled intraperitoneal catheter ","code_information":[{"code":"49422","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, continuous infusion by catheter (including catheter placement), including imaging guidance, when performed ","code_information":[{"code":"499","type":"RC"},{"code":"64448","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Angiography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"75716","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":137.520,"maximum":167.230,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":137.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":155.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":137.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":167.230,"methodology":"fee schedule"}]}]},{"description":"Patellectomy or hemipatellectomy ","code_information":[{"code":"27350","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area ","code_information":[{"code":"15760","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixation ","code_information":[{"code":"27846","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Preparation of moulage for custom breast implant ","code_information":[{"code":"19396","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus ","code_information":[{"code":"50961","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0DL77DZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17085.000,"maximum":17085.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17085.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motionºs» and/or ejection fractionºs», when performed); multiple studies at rest and stress (exercis ","code_information":[{"code":"618","type":"RC"},{"code":"78431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2318.010,"maximum":2318.010,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2318.010,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of lunate dislocation, with manipulation ","code_information":[{"code":"25690","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":4950.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4098.580,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4014.930,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each ","code_information":[{"code":"301","type":"RC"},{"code":"86316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.810,"maximum":24.970,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.970,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.430,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.810,"methodology":"fee schedule"}]}]},{"description":"Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, inc ","code_information":[{"code":"34710","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Descending thoracic aorta graft, with or without bypass ","code_information":[{"code":"33875","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Medial canthopexy (separate procedure) ","code_information":[{"code":"21280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8193.780,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Blood, l/r, cmv-neg ","code_information":[{"code":"9524","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":151.580,"maximum":159.160,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":153.100,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":156.130,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":159.160,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":151.580,"methodology":"fee schedule"},{"payer_name":"Eon 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schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":151.580,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":151.580,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":154.610,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia ","code_information":[{"code":"31298","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection, anidulafungin, 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J0348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.840,"maximum":0.840,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.840,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint ","code_information":[{"code":"26545","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when perfor ","code_information":[{"code":"367","type":"RC"},{"code":"52284","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, con ","code_information":[{"code":"49418","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"116","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1105.030,"maximum":1226.590,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1171.340,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1105.030,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1105.030,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1226.590,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1226.590,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification ","code_information":[{"code":"349","type":"RC"},{"code":"78469","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":259.890,"maximum":299.550,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":259.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":294.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":259.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":299.550,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage ","code_information":[{"code":"23101","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level ","code_information":[{"code":"0627T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant ","code_information":[{"code":"21390","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length ","code_information":[{"code":"490","type":"RC"},{"code":"64893","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING LEAD ONLY ","code_information":[{"code":"0429T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious disease (bacterial vaginosis and vaginitis), realtime amplification of DNA markers for Atopobium vaginae, Gardnerella vaginalis, Megasphaera types 1 and 2, bacterial vaginosis associated ","code_information":[{"code":"0557U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":262.990,"maximum":315.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":268.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":315.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":268.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":315.590,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":262.990,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":270.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":262.990,"methodology":"fee schedule"}]}]},{"description":"Tonsillectomy, primary or secondary; younger than age 12 ","code_information":[{"code":"42825","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; 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operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass ","code_information":[{"code":"33266","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"46600","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus ","code_information":[{"code":"28120","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia ","code_information":[{"code":"28540","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy ","code_information":[{"code":"45395","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OSTEOARTHRITIS; M > 37.65 ","code_information":[{"code":"148","type":"RC"},{"code":"D1201","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":15134.760,"maximum":16799.590,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":16042.850,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":15134.760,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":16799.590,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":15891.500,"methodology":"fee 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","code_information":[{"code":"63053","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on on ","code_information":[{"code":"306","type":"RC"},{"code":"81407","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":846.270,"maximum":1015.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":863.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1015.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":863.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1015.520,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":846.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":871.660,"methodology":"fee 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Transmyocardial laser revascularization, by thoracotomy; (separate procedure) ","code_information":[{"code":"33140","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case 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further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age ","code_information":[{"code":"360","type":"RC"},{"code":"36570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess) ","code_information":[{"code":"26034","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves ","code_information":[{"code":"27035","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"403","type":"RC"},{"code":"74250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Sperm evaluation; hamster penetration test ","code_information":[{"code":"309","type":"RC"},{"code":"89329","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.590,"maximum":23.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.510,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":19.590,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.180,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19.590,"methodology":"fee schedule"}]}]},{"description":"Carnitine (total and free), quantitative, each specimen ","code_information":[{"code":"314","type":"RC"},{"code":"82379","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.870,"maximum":17.380,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":16.870,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.380,"methodology":"fee schedule"}]}]},{"description":"Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) ","code_information":[{"code":"E0630","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":102.430,"maximum":110.880,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":106.660,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":108.770,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":110.880,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":105.600,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":110.880,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":110.880,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":106.660,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":106.660,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":106.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":105.600,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":102.430,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":105.600,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":110.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":107.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":105.600,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":105.600,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":107.710,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with allograft ","code_information":[{"code":"25126","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"NONTRAUMATIC BRAIN INJURY; M > 26.15 & M < 35.05 ","code_information":[{"code":"118","type":"RC"},{"code":"C0303","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":23314.240,"maximum":25878.800,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":24713.090,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":23314.240,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":25878.800,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":24479.950,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":23547.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":23547.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":23547.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":23314.240,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":25878.800,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":25878.800,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles) ","code_information":[{"code":"612","type":"RC"},{"code":"76857","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"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":"50431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Correction claw finger, other methods ","code_information":[{"code":"26499","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluoroscopy and/or ultrasound guidance, when performed; birth through 5 years of age or any age with congenital card ","code_information":[{"code":"33018","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Xcellistem, 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"A2004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":25.740,"maximum":25.740,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25.740,"methodology":"fee schedule"}]}]},{"description":"Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"49442","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg ","code_information":[{"code":"343","type":"RC"},{"code":"Q5146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":61.300,"maximum":61.300,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":61.300,"methodology":"fee schedule"}]}]},{"description":"Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal uret ","code_information":[{"code":"52649","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":11562.490,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":11562.490,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State 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adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Operculectomy, excision pericoronal tissues ","code_information":[{"code":"41821","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophageal motility ","code_information":[{"code":"78258","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":1010.490,"maximum":1031.540,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1031.540,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1010.490,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"155","type":"RC"},{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection, epinephrine (fresenius), not therapeutically equivalent to j0165, 0.1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J0162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.760,"maximum":0.760,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.760,"methodology":"fee schedule"}]}]},{"description":"Sperm washing for artificial insemination ","code_information":[{"code":"58323","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"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; of both tibia and fibula ","code_information":[{"code":"27828","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Open treatment of femoral shaft fracture with plate/screws, with or without cerclage ","code_information":[{"code":"27507","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":13741.230,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) ","code_information":[{"code":"367","type":"RC"},{"code":"43233","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (pan-tumor), genetic profiling of 8 DNA-regulatory markers by qPCR, whole blood, reported as a high or low probability of responding to immune checkpoint-inhibitor therapy ","code_information":[{"code":"0332U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1142.060,"maximum":1176.320,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1142.060,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1176.320,"methodology":"fee schedule"}]}]},{"description":"Conjunctival flap; bridge or partial (separate procedure) ","code_information":[{"code":"68360","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"204","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1022.540,"maximum":1022.540,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1022.540,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1022.540,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1022.540,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Suture of infrapatellar tendon; primary ","code_information":[{"code":"27380","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Trypsin; feces, qualitative ","code_information":[{"code":"304","type":"RC"},{"code":"84488","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.300,"maximum":8.760,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8.760,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.300,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.520,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.300,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views ","code_information":[{"code":"400","type":"RC"},{"code":"72114","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":98.570,"maximum":245.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":98.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":111.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":98.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":119.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":" Intensive Care Unit Burn Care  ","code_information":[{"code":"207","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_percentage":40.20,"standard_charge_algorithm":"Reimbursement will be 40.2% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform (eg, Miller type procedure) ","code_information":[{"code":"28737","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure) ","code_information":[{"code":"20934","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited ","code_information":[{"code":"349","type":"RC"},{"code":"76775","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm ","code_information":[{"code":"11626","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7187.750,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7187.750,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7041.060,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction ","code_information":[{"code":"0178U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":459.860,"maximum":551.830,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":469.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":551.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":469.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":551.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":473.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":459.860,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with control of bleeding, any method ","code_information":[{"code":"43227","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Free muscle or myocutaneous flap with microvascular anastomosis ","code_information":[{"code":"15756","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Medical physics dose evaluation for radiation exposure that exceeds institutional review threshold, including report ","code_information":[{"code":"403","type":"RC"},{"code":"76145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":546.520,"maximum":546.520,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":546.520,"methodology":"fee schedule"}]}]},{"description":"Adrenal cortical tumor, biochemical assay of 25 steroid markers, utilizing 24-hour urine specimen and clinical parameters, prognostic algorithm reported as a clinical risk and integrated clinical ster ","code_information":[{"code":"0015M","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1305.370,"maximum":1344.530,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1305.370,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1344.530,"methodology":"fee schedule"}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm ","code_information":[{"code":"11641","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material ","code_information":[{"code":"321","type":"RC"},{"code":"72146","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":197.080,"maximum":239.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":197.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":223.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":197.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":239.650,"methodology":"fee schedule"}]}]},{"description":"Intestinal allotransplantation; from living donor ","code_information":[{"code":"44136","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Strabismus surgery, recession or resection procedure; 2 horizontal muscles ","code_information":[{"code":"362","type":"RC"},{"code":"67312","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Interthoracoscapular amputation (forequarter) ","code_information":[{"code":"23900","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) ","code_information":[{"code":"31629","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or telescope ","code_information":[{"code":"31531","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Proctoplasty; for prolapse of mucous membrane ","code_information":[{"code":"360","type":"RC"},{"code":"45505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7549.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days ","code_information":[{"code":"616","type":"RC"},{"code":"78266","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":554.420,"maximum":554.420,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":554.420,"methodology":"fee schedule"}]}]},{"description":"Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure) ","code_information":[{"code":"32501","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7365.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"}]}]},{"description":"Repair blood vessel, direct; intra-abdominal ","code_information":[{"code":"35221","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Implantation or replacement of gastric neurostimulator electrodes, antrum, open ","code_information":[{"code":"43881","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoplasty, medialization, unilateral ","code_information":[{"code":"31591","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, polatuzumab vedotin-piiq, 1 mg ","code_information":[{"code":"J9309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":128.750,"maximum":341.220,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":21.58,"standard_charge_algorithm":"Reimbursement will be 21.58% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":146.000,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":155.460,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":341.220,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":128.750,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":334.250,"methodology":"fee schedule"}]}]},{"description":"Pediatric febrile illness (Kawasaki disease) interferon alphainducible protein 27 and mast cell-expressed membraine protein 1, RNA, using reverse transcription polymerase chain reaction, blood, report ","code_information":[{"code":"0389U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":70.200,"maximum":84.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":71.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":84.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":71.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":84.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":70.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":72.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":70.200,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material ","code_information":[{"code":"400","type":"RC"},{"code":"73721","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical 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":228.350,"maximum":277.680,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":228.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":259.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":228.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":277.680,"methodology":"fee schedule"}]}]},{"description":"Cyclic citrullinated peptide (CCP), antibody ","code_information":[{"code":"301","type":"RC"},{"code":"86200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.950,"maximum":15.540,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.540,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.950,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed ","code_information":[{"code":"480","type":"RC"},{"code":"50542","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Therapeutic apheresis; for platelets ","code_information":[{"code":"36513","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) ","code_information":[{"code":"322","type":"RC"},{"code":"71551","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":470.880,"maximum":572.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":470.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":534.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":470.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":572.600,"methodology":"fee schedule"}]}]},{"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Unlisted ultrasound procedure (eg, diagnostic, interventional) ","code_information":[{"code":"322","type":"RC"},{"code":"76999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Antibody; herpes simplex, type 2 ","code_information":[{"code":"307","type":"RC"},{"code":"86696","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.350,"maximum":23.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.220,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":19.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19.350,"methodology":"fee schedule"}]}]},{"description":"Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands ","code_information":[{"code":"369","type":"RC"},{"code":"42509","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Manipulation, hip joint, requiring general anesthesia ","code_information":[{"code":"27275","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic ","code_information":[{"code":"362","type":"RC"},{"code":"63003","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"312","type":"RC"},{"code":"87327","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.420,"maximum":13.820,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.420,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.820,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with maxillary antrostomy; ","code_information":[{"code":"31256","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion ","code_information":[{"code":"51030","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum ","code_information":[{"code":"43648","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Bronchoplasty; excision stenosis and anastomosis ","code_information":[{"code":"31775","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed ","code_information":[{"code":"31276","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":16434.380,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9829.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":9829.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9829.000,"methodology":"case rate"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":16434.380,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":16098.990,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Antibody; West Nile virus ","code_information":[{"code":"311","type":"RC"},{"code":"86789","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.390,"maximum":14.820,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.390,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.820,"methodology":"fee schedule"}]}]},{"description":"Hyaluronan or derivative, hymovis or hymovis one, for intra-articular injection, 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J7322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":29.110,"maximum":29.110,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29.110,"methodology":"fee schedule"}]}]},{"description":"Excision of submandibular (submaxillary) gland ","code_information":[{"code":"42440","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area ","code_information":[{"code":"15839","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure) ","code_information":[{"code":"321","type":"RC"},{"code":"74301","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.820,"maximum":11.820,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":11.820,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography with contrast, abdomen ","code_information":[{"code":"619","type":"RC"},{"code":"C8900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":828.270,"maximum":828.270,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) ","code_information":[{"code":"26121","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Chlamydia trachomatis ","code_information":[{"code":"301","type":"RC"},{"code":"87810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.290,"maximum":42.350,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.350,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.350,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.290,"methodology":"fee schedule"}]}]},{"description":"Probing of lacrimal canaliculi, with or without irrigation ","code_information":[{"code":"68840","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"HLA typing; lymphocyte culture, mixed (MLC) ","code_information":[{"code":"307","type":"RC"},{"code":"86821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.560,"maximum":43.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":43.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":43.870,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":36.560,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":37.660,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36.560,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"320","type":"RC"},{"code":"73223","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":457.410,"maximum":556.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":457.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":518.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":457.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":556.220,"methodology":"fee schedule"}]}]},{"description":"Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative ","code_information":[{"code":"303","type":"RC"},{"code":"82010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.170,"maximum":9.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8.330,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.800,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":8.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":8.170,"methodology":"fee schedule"}]}]},{"description":"Glucose; post glucose dose (includes glucose) ","code_information":[{"code":"310","type":"RC"},{"code":"82950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.750,"maximum":4.890,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.890,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"72130","type":"CPT"},{"code":"800856","type":"CDM"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":447.670,"maximum":456.990,"gross_charge":7012.25,"discounted_cash":7012.25,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":456.990,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":447.670,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, single view, specify level ","code_information":[{"code":"401","type":"RC"},{"code":"72020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy (List separately in addition to code for pr ","code_information":[{"code":"19294","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) ","code_information":[{"code":"36831","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, exon 12 variants ","code_information":[{"code":"301","type":"RC"},{"code":"81310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":246.520,"maximum":295.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":251.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":295.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":251.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":295.820,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":246.520,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":253.920,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":246.520,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medica ","code_information":[{"code":"409","type":"RC"},{"code":"76019","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":42.880,"maximum":52.150,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":42.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":48.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":42.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":52.150,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC ","code_information":[{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13500.000,"maximum":38133.540,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":34984.110,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":14653.700,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":34984.110,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":34984.110,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":34984.110,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":24988.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":31349.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":35562.760,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":14943.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":31349.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":38133.540,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":18135.760,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":14798.780,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":14798.780,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":17646.490,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":15088.950,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":19032.000,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":15088.950,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":14274.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":14653.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":14653.700,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":14653.700,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":14508.610,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":15088.950,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":17286.360,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":15088.950,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":15234.040,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14203.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":14508.610,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":14508.610,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":14798.780,"methodology":"fee schedule"}]}]},{"description":"Apol1 (apolipoprotein l1) (eg, chronic kidney disease), risk variants ","code_information":[{"code":"0355U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":137.000,"maximum":141.110,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":141.110,"methodology":"fee schedule"}]}]},{"description":"Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein ","code_information":[{"code":"361","type":"RC"},{"code":"36800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, elranatamab-bcmm, 1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J1323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":311.060,"maximum":311.060,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":311.060,"methodology":"fee schedule"}]}]},{"description":"SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS ","code_information":[{"code":"029","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13966.460,"maximum":15118.330,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":15118.330,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":13966.460,"methodology":"fee schedule"}]}]},{"description":"Injection procedure for wrist arthrography ","code_information":[{"code":"25246","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CACNA1A, full gene analysis, including small sequence changes in exonic and intronic regions, deletions duplications, Short Tandem Requests (STR) gene expansions, mobile element insertions, and varian ","code_information":[{"code":"0231U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":846.270,"maximum":871.660,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":846.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":871.660,"methodology":"fee schedule"}]}]},{"description":"Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); recontouring with multiple osteotomies and bone autografts (eg, barrel-stave procedure) (includes obtaining g ","code_information":[{"code":"499","type":"RC"},{"code":"61559","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination; humerus, minimum of 2 views ","code_information":[{"code":"402","type":"RC"},{"code":"73060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral ","code_information":[{"code":"42330","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Replantation, thumb (includes distal tip to MP joint), complete amputation ","code_information":[{"code":"20827","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection, partial or complete, phalangeal base, each toe ","code_information":[{"code":"28126","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Unlisted cytopathology procedure ","code_information":[{"code":"311","type":"RC"},{"code":"825052","type":"CDM"},{"code":"88199","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.760,"maximum":59.710,"gross_charge":93.25,"discounted_cash":93.25,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":50.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":59.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":50.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":59.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.760,"methodology":"fee schedule"}]}]},{"description":"Omental flap, intra-abdominal (List separately in addition to code for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"49905","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10560.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"External cephalic version, with or without tocolysis ","code_information":[{"code":"367","type":"RC"},{"code":"59412","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal or revision of sling for stress incontinence (eg, fascia or synthetic) ","code_information":[{"code":"369","type":"RC"},{"code":"57287","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7548.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed ","code_information":[{"code":"22838","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, congenital arteriovenous fistula; thorax and abdomen ","code_information":[{"code":"35182","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view ","code_information":[{"code":"329","type":"RC"},{"code":"72081","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.090,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":70.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":79.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":70.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":85.230,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Triiodothyronine T3; reverse ","code_information":[{"code":"305","type":"RC"},{"code":"84482","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.760,"maximum":18.910,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.910,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.760,"methodology":"fee schedule"}]}]},{"description":"Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) ","code_information":[{"code":"31000","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, hyaluronidase, up to 150 units ","drug_information":{"unit":1.500000000000000e+002,"type":"UN"},"code_information":[{"code":"636","type":"RC"},{"code":"917674","type":"CDM"},{"code":"J3470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":52.490,"maximum":52.490,"gross_charge":497.00,"discounted_cash":497.00,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":52.490,"methodology":"fee schedule"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); tibia ","code_information":[{"code":"27640","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections ","code_information":[{"code":"340","type":"RC"},{"code":"70492","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging ","code_information":[{"code":"51798","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of fracture of orbit, except blowout; with implant ","code_information":[{"code":"21407","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; 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common variant(s) (eg, A, A-) ","code_information":[{"code":"305","type":"RC"},{"code":"81247","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.810,"maximum":209.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":178.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":209.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":178.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":209.770,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":174.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":180.050,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":174.810,"methodology":"fee schedule"}]}]},{"description":"NONTRAUMATIC SPINAL CORD INJURY; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State 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rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Autoimmune diseases, analysis of 11 cytokine soluble mediator biomarkers by immunoassay, plasma, individual components reported with an algorithmic prognostic risk score for developing a clinical flar ","code_information":[{"code":"0447U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":840.650,"maximum":1008.780,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":857.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1008.780,"methodology":"fee 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rate"}]}]},{"description":"Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter ","code_information":[{"code":"49436","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4353.590,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4353.590,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4264.740,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of tendon, palm, flexor or extensor, single, each tendon ","code_information":[{"code":"26170","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Clotting; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Infectious disease (vaginal infection), identification of 32 pathogenic organisms, swab, real-time PCR, reported as positive or negative for each organism ","code_information":[{"code":"0505U","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":679.770,"maximum":700.160,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":679.770,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":700.160,"methodology":"fee schedule"}]}]},{"description":"Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan ","code_information":[{"code":"322","type":"RC"},{"code":"77338","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision or fulguration; urethral caruncle ","code_information":[{"code":"499","type":"RC"},{"code":"53265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) ","code_information":[{"code":"305","type":"RC"},{"code":"87220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.270,"maximum":5.120,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.120,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.270,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited ","code_information":[{"code":"321","type":"RC"},{"code":"76642","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":95.280,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":95.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, adductor of hip, open ","code_information":[{"code":"27001","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"367","type":"RC"},{"code":"49440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis ","code_information":[{"code":"43336","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"OTHER ORTHOPEDIC; M < 24.15 ","code_information":[{"code":"128","type":"RC"},{"code":"D0904","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":25910.790,"maximum":28760.980,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":27465.440,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":25910.790,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":28760.980,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":27206.330,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":26169.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":26169.900,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":26169.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":25910.790,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":28760.980,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":28760.980,"methodology":"fee schedule"}]}]},{"description":"REPLACEMENT OF LOWER EXTREMITY JOINT; M > 49.55 ","code_information":[{"code":"D0801","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":13985.890,"maximum":14571.610,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":14285.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13985.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":14285.890,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":14571.610,"methodology":"fee schedule"}]}]},{"description":"Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral ","code_information":[{"code":"409","type":"RC"},{"code":"77066","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":249.720,"maximum":303.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":249.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":283.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":249.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":303.660,"methodology":"fee schedule"}]}]},{"description":"Bone age studies ","code_information":[{"code":"400","type":"RC"},{"code":"77072","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":26.280,"maximum":31.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":26.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":29.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":26.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":31.960,"methodology":"fee schedule"}]}]},{"description":"NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER ","code_information":[{"code":"6074","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":44869.790,"maximum":45767.190,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":44869.790,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":45767.190,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":44869.790,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":44869.790,"methodology":"fee schedule"}]}]},{"description":"Drainage of scrotal wall abscess ","code_information":[{"code":"360","type":"RC"},{"code":"55100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of lesion of tongue with closure; posterior one-third ","code_information":[{"code":"369","type":"RC"},{"code":"41113","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Prostate cancer screening; prostate specific antigen test (psa) ","code_information":[{"code":"312","type":"RC"},{"code":"G0103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":19.310,"maximum":19.890,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":19.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.890,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, transvaginal ","code_information":[{"code":"610","type":"RC"},{"code":"76830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-arterial ","code_information":[{"code":"33947","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, with insertion of esophageal protection device and circumferential radiofrequency destruction of the pulmonary nerves, including fluoroscopic guidance when performed; ","code_information":[{"code":"0781T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":11794.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"HLA typing; DR/DQ, multiple antigens ","code_information":[{"code":"312","type":"RC"},{"code":"86817","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":106.140,"maximum":109.320,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":106.140,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.320,"methodology":"fee schedule"}]}]},{"description":"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC ","code_information":[{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4500.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3575.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":3575.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3575.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1671.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4500.000,"methodology":"per diem","additional_payer_notes":"Days 6+. "}]}]},{"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":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tonsillectomy and adenoidectomy; younger than age 12 ","code_information":[{"code":"42820","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed ","code_information":[{"code":"499","type":"RC"},{"code":"93451","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7098.810,"maximum":14070.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7098.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8052.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7098.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":8184.750,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14070.000,"methodology":"case rate"}]}]},{"description":"Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist admin ","code_information":[{"code":"320","type":"RC"},{"code":"70554","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":451.340,"maximum":548.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":451.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":511.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":451.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":548.840,"methodology":"fee schedule"}]}]},{"description":"Antibody; Leishmania ","code_information":[{"code":"302","type":"RC"},{"code":"86717","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.250,"maximum":14.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.620,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.250,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"409","type":"RC"},{"code":"72197","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":156.400,"maximum":190.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":156.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":177.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":156.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":190.180,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, elbow; complete, minimum of 3 views ","code_information":[{"code":"400","type":"RC"},{"code":"73080","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":52.650,"maximum":182.030,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":52.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":59.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":52.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":64.030,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":182.030,"methodology":"fee schedule"}]}]},{"description":"Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (List separately in additi ","code_information":[{"code":"10036","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, salivary gland for calculus ","code_information":[{"code":"321","type":"RC"},{"code":"70380","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":46.240,"maximum":56.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":46.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":52.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":46.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":56.220,"methodology":"fee schedule"}]}]},{"description":"Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff ","code_information":[{"code":"490","type":"RC"},{"code":"53445","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19095.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7875.580,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8933.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7875.580,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9579.770,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4403.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19095.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Actin (smooth muscle) antibody (ASMA), each ","code_information":[{"code":"301","type":"RC"},{"code":"86015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.530,"maximum":13.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.840,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.530,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, pelvis; with contrast material(s) ","code_information":[{"code":"610","type":"RC"},{"code":"72193","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Marsupialization of sublingual salivary cyst (ranula) ","code_information":[{"code":"42409","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, CERVICAL; MORE THAN 2 SEGMENTS ","code_information":[{"code":"63182","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Displacement therapy (Proetz type) ","code_information":[{"code":"30210","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) ","code_information":[{"code":"43265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":10256.960,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":10256.960,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5940.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5951.000,"methodology":"case rate"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":10047.640,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Removal of implanted material, posterior segment; extraocular ","code_information":[{"code":"361","type":"RC"},{"code":"67120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Surgery of intracranial arteriovenous malformation; dural, complex ","code_information":[{"code":"367","type":"RC"},{"code":"61692","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, hemin, 1 mg ","code_information":[{"code":"J1640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":32.080,"maximum":85.020,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":36.820,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":38.980,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":85.020,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":32.080,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":83.290,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, anus ","code_information":[{"code":"361","type":"RC"},{"code":"46999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State 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","code_information":[{"code":"499","type":"RC"},{"code":"51550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or without skin or skeletal traction ","code_information":[{"code":"27240","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator ","code_information":[{"code":"64569","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure) ","code_information":[{"code":"362","type":"RC"},{"code":"44955","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ciliary body destruction; cyclophotocoagulation, endoscopic, without concomitant removal of crystalline lens ","code_information":[{"code":"499","type":"RC"},{"code":"66711","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Treatment of tarsal bone fracture (except talus and calcaneus); 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"}]}]},{"description":"Radiologic examination; humerus, minimum of 2 views ","code_information":[{"code":"352","type":"RC"},{"code":"73060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) ","code_information":[{"code":"21188","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14439.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14439.000,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":14144.320,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification ","code_information":[{"code":"87527","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.760,"maximum":50.110,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":37.580,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":42.180,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":37.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":37.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":37.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":37.580,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":43.850,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":43.010,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":42.600,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":43.850,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":43.850,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":43.850,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":50.110,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":42.180,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":42.180,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":42.180,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":35.760,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":43.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":42.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":42.600,"methodology":"fee schedule"}]}]},{"description":"Gammaglobulin (immunoglobulin); 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC ","code_information":[{"code":"110","type":"RC"},{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10391.800,"maximum":12640.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. 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one antigen equivalent (eg, B*27), each ","code_information":[{"code":"304","type":"RC"},{"code":"81374","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":74.330,"maximum":89.200,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":75.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":89.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":75.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":89.200,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":74.330,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":76.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":74.330,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; 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with repair of enterocele ","code_information":[{"code":"367","type":"RC"},{"code":"58280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendonºs», muscleºs», nerveºs», other soft-tissue structureºs», or soft-tiss ","code_information":[{"code":"323","type":"RC"},{"code":"76882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":48.750,"maximum":109.530,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":48.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Psychiatry (suicidial ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score ","code_information":[{"code":"0293U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":912.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":912.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":912.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":782.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC ","code_information":[{"code":"298","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2663.290,"maximum":2882.940,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":2882.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":2663.290,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen (eg, Neisseria meningitidis, Streptococcus pneumoniae, Listeria, Haemophilus influenzae, E. coli, Streptococcus ","code_information":[{"code":"307","type":"RC"},{"code":"87483","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":500.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":500.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":425.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":500.140,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":429.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":416.780,"methodology":"fee schedule"}]}]},{"description":"Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan ","code_information":[{"code":"0746T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Drainage of ovarian abscess; vaginal approach, open ","code_information":[{"code":"499","type":"RC"},{"code":"58820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Bone marrow harvesting for transplantation; autologous ","code_information":[{"code":"38232","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique ","code_information":[{"code":"45309","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum ","code_information":[{"code":"11004","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Strapping; shoulder (eg, Velpeau) ","code_information":[{"code":"29240","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) ","code_information":[{"code":"343","type":"RC"},{"code":"J2790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":132.870,"maximum":132.870,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":132.870,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, patella; with prosthesis ","code_information":[{"code":"27438","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":39422.800,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Biliary endoscopy, percutaneous via T-tube or other tract; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal of foreign body, shoulder; deep (subfascial or intramuscular) ","code_information":[{"code":"23333","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) ","code_information":[{"code":"20225","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radial styloidectomy (separate procedure) ","code_information":[{"code":"25230","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chemodenervation of one extremity; 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cell-based immunofluorescence assay (CBA), each ","code_information":[{"code":"319","type":"RC"},{"code":"86362","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.050,"maximum":12.410,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.410,"methodology":"fee schedule"}]}]},{"description":"Osteotomy; multiple, with realignment on intramedullary rod (eg, Sofield type procedure) ","code_information":[{"code":"27712","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material ","code_information":[{"code":"352","type":"RC"},{"code":"74176","type":"CPT"},{"code":"811690","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":517.790,"gross_charge":4313.00,"discounted_cash":4313.00,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with percutaneous transluminal coronary lithotripsy ","code_information":[{"code":"369","type":"RC"},{"code":"C7571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"O.R. 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"}]}]},{"description":"Laryngoscopy, indirect; diagnostic (separate procedure) ","code_information":[{"code":"31505","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate-specific antigen, reported as likelihood of cancer ","code_information":[{"code":"0433U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":760.000,"maximum":912.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":912.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":775.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":912.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":760.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":782.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":760.000,"methodology":"fee schedule"}]}]},{"description":"Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis ","code_information":[{"code":"43332","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arterial puncture, withdrawal of blood for diagnosis ","code_information":[{"code":"36600","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4404.810,"maximum":9657.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"}]}]},{"description":"Susceptibility studies, antimicrobial agent; enzyme detection (eg, beta lactamase), per enzyme ","code_information":[{"code":"304","type":"RC"},{"code":"87185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.750,"maximum":5.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.750,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.750,"methodology":"fee schedule"}]}]},{"description":"Use of ophthalmic endoscope (List separately in addition to code for primary procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"66990","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List separately in addition to code for primary procedure) ","code_information":[{"code":"33519","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hydroxyzine pamoate, 25 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 ho ","code_information":[{"code":"344","type":"RC"},{"code":"Q0177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.300,"maximum":3.300,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.300,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, mandible, segmental; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infant ","code_information":[{"code":"15157","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vanillylmandelic acid (VMA), urine ","code_information":[{"code":"84585","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":15.500,"maximum":18.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.500,"methodology":"fee schedule"}]}]},{"description":"Simple cystometrogram (CMG) (eg, spinal manometer) ","code_information":[{"code":"360","type":"RC"},{"code":"51725","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair of spica, body cast or jacket ","code_information":[{"code":"29720","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13500.000,"maximum":90174.360,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":82726.910,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":32276.940,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":82726.910,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":82726.910,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":82726.910,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":59090.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":74132.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":84095.230,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":32916.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":74132.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":90174.360,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":39946.710,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":32596.520,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":32596.520,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":41115.620,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":33235.660,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":45004.960,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":33235.660,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":33753.720,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":32276.940,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":32276.940,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":32276.940,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":31957.370,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":33235.660,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":40276.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":33235.660,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":33555.240,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":31286.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":31957.370,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":31957.370,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":32596.520,"methodology":"fee schedule"}]}]},{"description":"Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disea ","code_information":[{"code":"312","type":"RC"},{"code":"86328","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":45.280,"maximum":46.640,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":45.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":46.640,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed ","code_information":[{"code":"361","type":"RC"},{"code":"44408","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Coronary artery bypass, vein only; 5 coronary venous grafts ","code_information":[{"code":"33514","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Strabismus surgery, recession or resection procedure; 2 horizontal muscles ","code_information":[{"code":"480","type":"RC"},{"code":"67312","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed ","code_information":[{"code":"499","type":"RC"},{"code":"77778","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20667.700,"maximum":25139.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23445.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20667.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25139.900,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"303","type":"RC"},{"code":"87391","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.900,"maximum":26.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":22.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":26.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":22.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26.280,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.560,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.900,"methodology":"fee schedule"}]}]},{"description":"Application of clubfoot cast with molding or manipulation, long or short leg ","code_information":[{"code":"29450","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Decompression, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle-based technique to remove disc material under fluoroscopic imaging or other form of indirect visual ","code_information":[{"code":"62287","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when p ","code_information":[{"code":"20983","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age ","code_information":[{"code":"33969","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dilation salivary duct ","code_information":[{"code":"42650","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Osteotomy, pelvis, bilateral (eg, congenital malformation) ","code_information":[{"code":"27158","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Alpha-1-antitrypsin; total ","code_information":[{"code":"302","type":"RC"},{"code":"82103","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.440,"maximum":16.130,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.130,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.440,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) ","code_information":[{"code":"0029U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":742.270,"maximum":890.720,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":757.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":890.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":757.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":890.720,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":742.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":764.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":742.270,"methodology":"fee schedule"}]}]},{"description":"Neurology Alzheimer Disease Quantitative Imaging ","code_information":[{"code":"0207U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":511.200,"maximum":613.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":521.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":613.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":521.420,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":613.440,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":511.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":526.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":511.200,"methodology":"fee schedule"}]}]},{"description":"HLA typing; 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with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, pl ","code_information":[{"code":"44378","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Transcatheter left ventricular restoration device implantation including right and left heart catheterization and left ventriculography when performed, arterial approach ","code_information":[{"code":"0643T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of interphalangeal joint dislocation; without anesthesia ","code_information":[{"code":"28660","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, cervical spine; with contrast material ","code_information":[{"code":"401","type":"RC"},{"code":"72126","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":367.840,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"}]}]},{"description":"Protein, total, except by refractometry; serum, plasma or whole blood ","code_information":[{"code":"301","type":"RC"},{"code":"84155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.670,"maximum":4.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.400,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3.670,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.670,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum ","code_information":[{"code":"361","type":"RC"},{"code":"43647","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19440.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, ","code_information":[{"code":"0007U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":114.430,"maximum":117.860,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":114.430,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":117.860,"methodology":"fee schedule"}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and la ","code_information":[{"code":"490","type":"RC"},{"code":"67043","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reduction ","code_information":[{"code":"26686","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, bevacizumab, 0.25 mg ","code_information":[{"code":"C9257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.600,"maximum":4.690,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4.690,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4.600,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction ","code_information":[{"code":"24505","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"O.R. 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logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each ","code_information":[{"code":"86971","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":291.260,"maximum":349.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":349.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":349.510,"methodology":"fee 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Red cell antigen (Dombrock blood group) genotyping (DO), gene analysis ART4 (ADP-ribosyltransferase 4) exon 2 ","code_information":[{"code":"0184U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":185.200,"maximum":222.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":190.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"Albumin; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4337.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"329","type":"RC"},{"code":"73723","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":455.250,"maximum":553.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":455.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":516.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":455.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":553.600,"methodology":"fee schedule"}]}]},{"description":"Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) ","code_information":[{"code":"362","type":"RC"},{"code":"43113","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coagulation/fibrinolysis assay, whole blood (eg, viscoelastic clot assessment), including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day ","code_information":[{"code":"302","type":"RC"},{"code":"85396","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.890,"maximum":23.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19.890,"methodology":"fee schedule"}]}]},{"description":"Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combinatio ","code_information":[{"code":"301","type":"RC"},{"code":"81535","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":579.460,"maximum":695.350,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":591.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":695.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":591.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":695.350,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":579.460,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":596.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":579.460,"methodology":"fee schedule"}]}]},{"description":"Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guida ","code_information":[{"code":"50080","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cm ","code_information":[{"code":"22904","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) ","code_information":[{"code":"58110","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic approach ","code_information":[{"code":"60505","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope ","code_information":[{"code":"31571","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days ","code_information":[{"code":"611","type":"RC"},{"code":"78266","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":554.420,"maximum":554.420,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":554.420,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation ","code_information":[{"code":"76813","type":"CPT"},{"code":"816463","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":122.260,"maximum":122.260,"gross_charge":1046.75,"discounted_cash":1046.75,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":122.260,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":122.260,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":122.260,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":122.260,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":122.260,"methodology":"fee schedule"}]}]},{"description":"Vitamin K ","code_information":[{"code":"310","type":"RC"},{"code":"84597","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.720,"maximum":14.130,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.720,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.130,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique ","code_information":[{"code":"87591","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":42.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Repair of anomalous coronary artery from pulmonary artery origin; by graft, with cardiopulmonary bypass ","code_information":[{"code":"33504","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITH CC ","code_information":[{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13500.000,"maximum":43941.090,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":40312.020,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":16620.380,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":40312.020,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":40312.020,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":40312.020,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":28794.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36124.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":40978.790,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":16949.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36124.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":43941.090,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":20569.780,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":16784.940,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":16784.940,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":20389.840,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":17114.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21930.480,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":17114.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":16447.860,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":16620.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":16620.380,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":16620.380,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":16455.820,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":17114.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":19973.720,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":17114.050,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":17278.610,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16110.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":16455.820,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":16455.820,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":16784.940,"methodology":"fee schedule"}]}]},{"description":"Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate procedure) ","code_information":[{"code":"33496","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Necropsy (autopsy), gross and microscopic; infant with brain ","code_information":[{"code":"311","type":"RC"},{"code":"88028","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":210.410,"maximum":252.490,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":214.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":252.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":214.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":252.490,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":210.410,"methodology":"fee schedule"}]}]},{"description":"Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision ","code_information":[{"code":"304","type":"RC"},{"code":"88152","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.640,"maximum":28.470,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":28.470,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"409","type":"RC"},{"code":"70546","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":636.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":523.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":593.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":523.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":636.590,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) ","code_information":[{"code":"28310","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants ","code_information":[{"code":"305","type":"RC"},{"code":"81212","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":440.000,"maximum":528.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":448.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":528.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":448.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":528.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":440.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":453.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":440.000,"methodology":"fee schedule"}]}]},{"description":"Vasovasostomy, vasovasorrhaphy ","code_information":[{"code":"55400","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir ","code_information":[{"code":"481","type":"RC"},{"code":"54405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4403.000,"maximum":33901.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":27870.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":31615.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":27870.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":33901.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4403.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":30150.000,"methodology":"case rate"}]}]},{"description":"Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation ","code_information":[{"code":"20824","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, lower extremity; with contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"73701","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":82.300,"maximum":100.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":82.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":93.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":82.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":100.080,"methodology":"fee schedule"}]}]},{"description":"Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) ","code_information":[{"code":"33413","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Drug Assay, presumptive, 30 or more drugs or metabolites, urine, liquid chromatography with tandem mass spectrometry using multiple reaction monitoring w drug or metabolite description, incl simple va ","code_information":[{"code":"0227U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":62.140,"maximum":74.570,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":63.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":74.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":63.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":74.570,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":62.140,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":64.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":62.140,"methodology":"fee schedule"}]}]},{"description":"Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna ","code_information":[{"code":"25119","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC  IPF","code_information":[{"code":"1002","type":"RC"},{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":873.610,"maximum":873.610,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":873.610,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"HLaryngotomy (thyrotomy, laryngofissure); diagnostic ","code_information":[{"code":"31320","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10520.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with ","code_information":[{"code":"50557","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multi ","code_information":[{"code":"15017","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, abdomen; 1 view ","code_information":[{"code":"409","type":"RC"},{"code":"74018","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":13.400,"maximum":16.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.290,"methodology":"fee schedule"}]}]},{"description":"Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary procedure) ","code_information":[{"code":"33517","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC One Day Stay","code_information":[{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells (eg, for derivatives and markers) ","code_information":[{"code":"307","type":"RC"},{"code":"88272","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.700,"maximum":41.920,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":40.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":41.920,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) ","code_information":[{"code":"361","type":"RC"},{"code":"G6025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of pleural-peritoneal shunt with intercostal pump chamber, including imaging, injection(s) of contrast with radiological supervision and interpretation, when performed ","code_information":[{"code":"480","type":"RC"},{"code":"C8006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8702.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) ","code_information":[{"code":"27006","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Harvesting conjunctival allograft, living donor ","code_information":[{"code":"369","type":"RC"},{"code":"68371","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm ","code_information":[{"code":"17264","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cardiac output measurement(s), thermodilution or other indicator dilution method, performed during cardiac catheterization for the evaluation of congenital heart defects (List separately in addition t ","code_information":[{"code":"361","type":"RC"},{"code":"93598","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":1669.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, eyelids ","code_information":[{"code":"480","type":"RC"},{"code":"67999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solut ","code_information":[{"code":"480","type":"RC"},{"code":"62325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination; sternoclavicular joint or joints, minimum of 3 views ","code_information":[{"code":"342","type":"RC"},{"code":"71130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal ao ","code_information":[{"code":"35081","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Adding walker to previously applied cast ","code_information":[{"code":"29440","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SEPTIC ARTHRITIS WITH CC Pediatric","code_information":[{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":18957.870,"maximum":26540.290,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":26540.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":26540.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":26540.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":26540.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":18957.870,"methodology":"fee schedule"}]}]},{"description":"Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis ","code_information":[{"code":"33418","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform exp ","code_information":[{"code":"304","type":"RC"},{"code":"81455","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2919.600,"maximum":3503.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2977.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3503.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2977.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3503.520,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2919.600,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3007.190,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2919.600,"methodology":"fee schedule"}]}]},{"description":"EMBOLIZATION UTERINE FIBROID ","code_information":[{"code":"37210","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Peritoneogram (eg, after injection of air or contrast), radiological supervision and interpretation ","code_information":[{"code":"403","type":"RC"},{"code":"74190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":564.750,"maximum":564.750,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":564.750,"methodology":"fee schedule"}]}]},{"description":"Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustmen ","code_information":[{"code":"L1851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":893.830,"maximum":967.540,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":930.680,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":949.110,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":967.540,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":921.470,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":967.540,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":967.540,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":930.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":930.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":930.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":921.470,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":893.830,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":921.470,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":967.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":939.900,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":921.470,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":921.470,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":939.900,"methodology":"fee schedule"}]}]},{"description":"Craniectomy or craniotomy, drainage of intracranial abscess; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"DEPRESSIVE NEUROSES  IPF","code_information":[{"code":"146","type":"RC"},{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1032.100,"maximum":1145.630,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1094.020,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1032.100,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1032.100,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1145.630,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1145.630,"methodology":"fee schedule","additional_payer_notes":"Days 5. 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with stentless tissue valve ","code_information":[{"code":"33410","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Free osteocutaneous flap with microvascular anastomosis; great toe with web space ","code_information":[{"code":"20973","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Biopsy, prostate, transperineal, ultrasound-guided (ie, sextant, ultrasound-localized discrete lesionºs») ","code_information":[{"code":"361","type":"RC"},{"code":"55709","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg ","code_information":[{"code":"892","type":"RC"},{"code":"Q5117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":84.880,"maximum":84.880,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":84.880,"methodology":"fee schedule"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus ","code_information":[{"code":"31288","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; pulse generator only ","code_information":[{"code":"64656","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":25200.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":25200.000,"methodology":"case rate"}]}]},{"description":"Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract ","code_information":[{"code":"33414","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed ","code_information":[{"code":"359","type":"RC"},{"code":"74262","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":401.740,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":401.740,"methodology":"fee schedule"}]}]},{"description":"Dibucaine number ","code_information":[{"code":"310","type":"RC"},{"code":"82638","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.250,"maximum":12.620,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.620,"methodology":"fee schedule"}]}]},{"description":"DESTROY NERVE EXTREM MUSC ","code_information":[{"code":"64614","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Plastic operation of penis for injury ","code_information":[{"code":"480","type":"RC"},{"code":"54440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rhinoplasty, primary; including major septal repair ","code_information":[{"code":"30420","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Laparoscopy, surgical, colostomy or skin level cecostomy ","code_information":[{"code":"44188","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10979.300,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, percutaneous, adductor or hamstring; multiple tendons ","code_information":[{"code":"27307","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair blood vessel with graft other than vein; lower extremity ","code_information":[{"code":"35286","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"75889","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":76.960,"maximum":93.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":76.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":87.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":76.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":93.590,"methodology":"fee schedule"}]}]},{"description":"Closure of rectovaginal fistula; vaginal or transanal approach ","code_information":[{"code":"362","type":"RC"},{"code":"57300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of hypospadias complication(s) (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps and urethroplasty with flap or patch graft ","code_information":[{"code":"360","type":"RC"},{"code":"54344","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (eg, laser) ","code_information":[{"code":"45320","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CESAREAN SECTION WITH STERILIZATION WITH CC ","code_information":[{"code":"156","type":"RC"},{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Procalcitonin (PCT) ","code_information":[{"code":"310","type":"RC"},{"code":"84145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.220,"maximum":28.040,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":28.040,"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":"490","type":"RC"},{"code":"49185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Autoimmune diseases, analysis of 11 cytokine soluble mediator biomarkers by immunoassay, plasma, individual components reported with an algorithmic prognostic risk score for developing a clinical flar ","code_information":[{"code":"0447U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":840.650,"maximum":865.870,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":840.650,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":865.870,"methodology":"fee schedule"}]}]},{"description":"Application of short leg cast (below knee to toes); ","code_information":[{"code":"29405","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Arthroplasty, ankle; ","code_information":[{"code":"27700","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) ","code_information":[{"code":"400","type":"RC"},{"code":"70542","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":114.940,"maximum":139.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":114.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":130.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":114.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":139.770,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3719.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1671.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3719.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"Impression and custom preparation; palatal augmentation prosthesis ","code_information":[{"code":"21082","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material ","code_information":[{"code":"618","type":"RC"},{"code":"72141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":517.790,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, adductor of hip, open ","code_information":[{"code":"27001","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair blood vessel, direct; upper extremity ","code_information":[{"code":"35206","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"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; each additional lesion, i ","code_information":[{"code":"19082","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed ","code_information":[{"code":"46258","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (Lis ","code_information":[{"code":"499","type":"RC"},{"code":"64494","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis, utilizing formalin-fixed paraffin-embedded tissue ","code_information":[{"code":"0111U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":682.290,"maximum":818.750,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":695.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":818.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":695.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":818.750,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":682.290,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":702.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":682.290,"methodology":"fee schedule"}]}]},{"description":"Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time ","code_information":[{"code":"323","type":"RC"},{"code":"76000","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":23.580,"maximum":28.670,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":23.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":26.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":23.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28.670,"methodology":"fee schedule"}]}]},{"description":"Conjunctivoplasty; with conjunctival graft or extensive rearrangement ","code_information":[{"code":"369","type":"RC"},{"code":"68320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"MAJ MULT TRAUMA NO BRAIN OR SPINAL CORD INJURY; M ","code_information":[{"code":"118","type":"RC"},{"code":"D1702","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19264.770,"maximum":21383.890,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20420.660,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19264.770,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21383.890,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20228.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19457.420,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19457.420,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19457.420,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19264.770,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":21383.890,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":21383.890,"methodology":"fee schedule"}]}]},{"description":"Tau, phosphorylated (eg, pTau 181, pTau 217), each ","code_information":[{"code":"307","type":"RC"},{"code":"84393","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":128.920,"maximum":154.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":131.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":154.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":131.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":154.700,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":128.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":132.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":128.920,"methodology":"fee schedule"}]}]},{"description":"Nerve repair; with nerve allograft, each additional strand (List separately in addition to code for primary procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"64913","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage ","code_information":[{"code":"53420","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) ","code_information":[{"code":"321","type":"RC"},{"code":"75565","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":52.140,"maximum":88.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":72.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":82.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":72.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":88.240,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":52.140,"methodology":"fee schedule"}]}]},{"description":"APPLY SKN XGRFT F/N/HF/G ADD ","code_information":[{"code":"15421","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach ","code_information":[{"code":"62165","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cardiopulmonary resuscitation (eg, in cardiac arrest) ","code_information":[{"code":"369","type":"RC"},{"code":"92950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":2028.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Injection procedure for myelography and/or computed tomography, lumbar ","code_information":[{"code":"499","type":"RC"},{"code":"62284","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Removal of foreign body, external eye; conjunctival superficial ","code_information":[{"code":"360","type":"RC"},{"code":"65205","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in ","code_information":[{"code":"22870","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) ","code_information":[{"code":"349","type":"RC"},{"code":"70481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, osseous survey; complete (axial and appendicular skeleton) ","code_information":[{"code":"321","type":"RC"},{"code":"77075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":245.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":155.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":176.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":155.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":189.540,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":110.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Surgery of intracranial arteriovenous malformation; dural, complex ","code_information":[{"code":"61692","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"TRAUMATIC BRAIN INJURY; M > 53.35 & C > 23.5 ","code_information":[{"code":"118","type":"RC"},{"code":"D0201","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":12419.010,"maximum":13785.100,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":13164.150,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":12419.010,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":13785.100,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":13039.960,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":12543.200,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":12543.200,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":12543.200,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":12419.010,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":13785.100,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":13785.100,"methodology":"fee schedule"}]}]},{"description":"Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod ","code_information":[{"code":"26390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":13741.230,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique ","code_information":[{"code":"87563","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.050,"maximum":42.110,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":31.580,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":32.970,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":36.140,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":32.030,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":30.050,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":36.840,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":35.790,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography without contrast followed by with contrast, pelvis ","code_information":[{"code":"618","type":"RC"},{"code":"C8920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":828.270,"maximum":828.270,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":828.270,"methodology":"fee schedule"}]}]},{"description":"Factor viii fc fusion rec ","code_information":[{"code":"01656","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2.390,"maximum":2.390,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":2.390,"methodology":"fee schedule"}]}]},{"description":"Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection ","code_information":[{"code":"369","type":"RC"},{"code":"51050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in addition to code for primary procedure) ","code_information":[{"code":"27358","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Open treatment of posterior or anterior acetabular wall fracture, with internal fixation ","code_information":[{"code":"27226","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of post hip arthroplasty dislocation; without anesthesia ","code_information":[{"code":"27265","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tracheal puncture, percutaneous with transtracheal aspiration and/or injection ","code_information":[{"code":"31612","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Dressing change (for other than burns) under anesthesia (other than local) ","code_information":[{"code":"15852","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation onc ","code_information":[{"code":"400","type":"RC"},{"code":"77336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":136.750,"maximum":136.750,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":136.750,"methodology":"fee schedule"}]}]},{"description":"Fixation of contralateral testis (separate procedure) ","code_information":[{"code":"54620","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each ","code_information":[{"code":"28515","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sedimentation rate, erythrocyte; automated ","code_information":[{"code":"305","type":"RC"},{"code":"804012","type":"CDM"},{"code":"85652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2.700,"maximum":3.240,"gross_charge":70.00,"discounted_cash":70.00,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2.700,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2.700,"methodology":"fee schedule"}]}]},{"description":"Injection, allopurinol sodium, 1 mg ","code_information":[{"code":"891","type":"RC"},{"code":"J0206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7.260,"maximum":7.260,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.260,"methodology":"fee schedule"}]}]},{"description":"Strapping; ankle and/or foot ","code_information":[{"code":"29540","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER FACTORS INFLUENCING HEALTH STATUS ","code_information":[{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3719.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1671.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 2+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3719.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"CARDIAC; M > 38.55 & M < 48.85 ","code_information":[{"code":"128","type":"RC"},{"code":"B1402","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":22930.870,"maximum":25453.270,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":24306.730,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":22930.870,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":25453.270,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":24077.420,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":23160.180,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":23160.180,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":23160.180,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":22930.870,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":25453.270,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":25453.270,"methodology":"fee schedule"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion ","code_information":[{"code":"38210","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary procedure) ","code_information":[{"code":"38102","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC* ","code_information":[{"code":"439","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3888.440,"maximum":4209.140,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":4209.140,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":3888.440,"methodology":"fee schedule"}]}]},{"description":"Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code) ","code_information":[{"code":"15854","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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 DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10391.800,"maximum":12640.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11788.400,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10391.800,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12640.500,"methodology":"case rate","additional_payer_notes":"Days 1 - 2. "}]}]},{"description":"Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization ºCGH» microarray analysis ","code_information":[{"code":"306","type":"RC"},{"code":"81228","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":900.000,"maximum":1080.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":918.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1080.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":918.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1080.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":900.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":927.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":900.000,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC Pediatric","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":30908.610,"maximum":43270.880,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":43270.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":43270.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":43270.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":43270.880,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":30908.610,"methodology":"fee schedule"}]}]},{"description":"Incision of lingual frenum (frenotomy) ","code_information":[{"code":"41010","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Keratoplasty (corneal transplant); endothelial ","code_information":[{"code":"65756","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with repair of subpulmonic obstruction ","code_information":[{"code":"33781","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":" Other Therapeutic Services Cardiac Rehabilitation  ","code_information":[{"code":"943","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":347.860,"maximum":500.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":347.860,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":394.610,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":347.860,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":423.140,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":500.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, shoulder area; single tendon ","code_information":[{"code":"23405","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Penile revascularization, artery, with or without vein graft ","code_information":[{"code":"37788","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu ","code_information":[{"code":"891","type":"RC"},{"code":"J7182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.560,"maximum":2.560,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2.560,"methodology":"fee schedule"}]}]},{"description":"Fetal congenital abnormalities, biochemical assays of two proteins (PAPP-A, hCG ºany form»), utilizing maternal serum, algorithm reported as a risk score ","code_information":[{"code":"81508","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":54.300,"maximum":65.160,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":55.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":65.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":55.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":65.160,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":55.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":54.300,"methodology":"fee schedule"}]}]},{"description":"Open treatment of proximal fibula or shaft fracture, includes internal fixation, when performed ","code_information":[{"code":"27784","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) ","code_information":[{"code":"610","type":"RC"},{"code":"76706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"63621","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) wit ","code_information":[{"code":"340","type":"RC"},{"code":"78832","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":144.790,"maximum":166.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":144.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":164.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":144.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":166.890,"methodology":"fee schedule"}]}]},{"description":"Open treatment of talus fracture, includes internal fixation, when performed ","code_information":[{"code":"28445","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) ","code_information":[{"code":"302","type":"RC"},{"code":"86335","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.350,"maximum":35.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":29.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":35.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":29.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35.220,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":29.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":30.230,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29.350,"methodology":"fee schedule"}]}]},{"description":"Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure) ","code_information":[{"code":"11201","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) ","code_information":[{"code":"333","type":"RC"},{"code":"61800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11757.000,"maximum":36366.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":29896.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":33914.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":29896.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":36366.300,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11757.000,"methodology":"case rate"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":18000.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36180.000,"methodology":"case rate"}]}]},{"description":"Open treatment of sesamoid fracture, with or without internal fixation ","code_information":[{"code":"28531","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ANOSCOPY W/RF DELIVERY ","code_information":[{"code":"0288T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7549.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Partial hymenectomy or revision of hymenal ring ","code_information":[{"code":"499","type":"RC"},{"code":"56700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) ","code_information":[{"code":"0030U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":134.130,"maximum":160.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":136.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":160.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":136.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":160.960,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":134.130,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":138.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":134.130,"methodology":"fee schedule"}]}]},{"description":"Thyroidectomy, total or complete ","code_information":[{"code":"480","type":"RC"},{"code":"60240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Urography, antegrade, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"74425","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":36.540,"maximum":44.430,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":36.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":41.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":36.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":44.430,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; common carotid-ipsilateral internal carotid ","code_information":[{"code":"35601","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"323","type":"RC"},{"code":"74174","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":447.560,"maximum":544.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":447.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":507.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":447.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":544.240,"methodology":"fee schedule"}]}]},{"description":"Ligation, major artery (eg, post-traumatic, rupture); chest ","code_information":[{"code":"369","type":"RC"},{"code":"37616","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION, LOWER EXTREMITY; M > 36.25 & M < 47.65 ","code_information":[{"code":"B1002","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":23542.150,"maximum":24528.080,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":24047.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":23542.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":24047.140,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":24528.080,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy ","code_information":[{"code":"44210","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts ","code_information":[{"code":"33535","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Harvest of skin for tissue cultured skin autograft, 100 sq cm or less ","code_information":[{"code":"15040","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, m ","code_information":[{"code":"15004","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal traction ","code_information":[{"code":"27232","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thoracoplasty, Schede type or extrapleural (all stages); ","code_information":[{"code":"32905","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies ","code_information":[{"code":"44111","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC One Day Stay","code_information":[{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire ","code_information":[{"code":"43248","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification ","code_information":[{"code":"301","type":"RC"},{"code":"87652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.760,"maximum":50.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":42.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":42.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.110,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":43.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":41.760,"methodology":"fee schedule"}]}]},{"description":"Cartilage graft; costochondral ","code_information":[{"code":"20910","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, talus or calcaneus; ","code_information":[{"code":"28100","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and ","code_information":[{"code":"312","type":"RC"},{"code":"81462","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1195.830,"maximum":1231.700,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1195.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1231.700,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy ","code_information":[{"code":"29900","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site ","code_information":[{"code":"362","type":"RC"},{"code":"36575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":9657.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"Goniotomy ","code_information":[{"code":"65820","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone and/or joint imaging; limited area ","code_information":[{"code":"349","type":"RC"},{"code":"78300","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.290,"maximum":49.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":49.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":49.900,"methodology":"fee schedule"}]}]},{"description":"Injection, gemtuzumab ozogamicin, 0.1 mg ","code_information":[{"code":"636","type":"RC"},{"code":"J9203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":396.280,"maximum":396.280,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":396.280,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) ","code_information":[{"code":"27006","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RHD & RHCE Gnotyp Next-Genrj Seq RH Prox Promoter ","code_information":[{"code":"0222U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":282.880,"maximum":339.460,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":288.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":339.460,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":288.540,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":339.460,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":282.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":291.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":282.880,"methodology":"fee schedule"}]}]},{"description":"Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) ","code_information":[{"code":"27720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":13741.230,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon ","code_information":[{"code":"26480","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Gallium gozellix 1 millic ","code_information":[{"code":"876","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1171.300,"maximum":1229.870,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1183.010,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":1206.440,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1229.870,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1171.300,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1229.870,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1229.870,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":1183.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":1183.010,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":1183.010,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1171.300,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1171.300,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":1229.870,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1194.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":1171.300,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1171.300,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":1194.730,"methodology":"fee schedule"}]}]},{"description":"Myelography, 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"72270","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":118.490,"maximum":144.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":118.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":134.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":118.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":144.090,"methodology":"fee schedule"}]}]},{"description":"UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC ","code_information":[{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13243.620,"maximum":35380.840,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":32458.750,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":13721.520,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":32458.750,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":32458.750,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":32458.750,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":23184.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":29086.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":32995.630,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":13993.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":29086.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35380.840,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":16982.080,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":13857.370,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":13857.370,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":16349.130,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":14129.090,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17658.160,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":14129.090,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":13243.620,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":13721.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":13721.520,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":13721.520,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":13585.660,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":14129.090,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":16015.480,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":14129.090,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 5. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":14264.940,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13300.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":13585.660,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":13585.660,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":13857.370,"methodology":"fee schedule"}]}]},{"description":"Excision of infected graft; thorax ","code_information":[{"code":"35905","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary ","code_information":[{"code":"37259","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rare diseases (constitutional disease/hereditary disorders), rapid whole genome DNA sequencing for singlenucleotide variants, insertions/deletions, copy number variations, blood, ","code_information":[{"code":"0582U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7582.200,"maximum":9098.640,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7733.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9098.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7733.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9098.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7809.670,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7582.200,"methodology":"fee schedule"}]}]},{"description":"Semi-precision abutment - placement ","code_information":[{"code":"790","type":"RC"},{"code":"D6191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":3415.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Chondroitin B sulfate, quantitative ","code_information":[{"code":"301","type":"RC"},{"code":"82485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.650,"maximum":24.780,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.060,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.780,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.650,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.650,"methodology":"fee schedule"}]}]},{"description":"Esophagostomy, fistulization of esophagus, external; cervical approach ","code_information":[{"code":"43352","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography) ","code_information":[{"code":"92285","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":98.710,"maximum":100.760,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":100.760,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":98.710,"methodology":"fee schedule"}]}]},{"description":"Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy ","code_information":[{"code":"481","type":"RC"},{"code":"50593","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Ablation, open, of 1 or more liver tumor(s); radiofrequency ","code_information":[{"code":"47380","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix ","code_information":[{"code":"361","type":"RC"},{"code":"57461","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Resection, diaphragm; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Therapeutic drug monitoring, 90 or more pain and mental health drugs or substances, LC-MS/MS, plasma, qualitative and quantitative therpeutic minimally effective range of prescribed and non-prescribed ","code_information":[{"code":"0518U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":246.920,"maximum":296.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":251.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":296.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":251.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":296.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":246.920,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":254.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":246.920,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor VIII (AHG), 1-stage ","code_information":[{"code":"300","type":"RC"},{"code":"85240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.900,"maximum":21.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.480,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.900,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.900,"methodology":"fee schedule"}]}]},{"description":"Pulmonary artery embolectomy; with cardiopulmonary bypass ","code_information":[{"code":"33910","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"114","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1019.840,"maximum":1132.020,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1081.030,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1132.020,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1070.830,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1019.840,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1132.020,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1132.020,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Hiv antigen/antibody, combination assay, screening ","code_information":[{"code":"303","type":"RC"},{"code":"G0475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":24.080,"maximum":28.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":24.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":28.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":24.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":28.900,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":24.080,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":24.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":24.080,"methodology":"fee schedule"}]}]},{"description":"Injection, interferon, alfa-2a, recombinant, 3 million units ","code_information":[{"code":"343","type":"RC"},{"code":"J9213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":57.870,"maximum":57.870,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":57.870,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique ","code_information":[{"code":"362","type":"RC"},{"code":"43251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) ","code_information":[{"code":"37500","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure (eg, rendezvous procedure), percutaneous, including diagnostic cholangiography when per ","code_information":[{"code":"47541","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, finger(s), minimum of 2 views ","code_information":[{"code":"320","type":"RC"},{"code":"73140","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":52.700,"maximum":64.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":52.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":59.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":52.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":64.080,"methodology":"fee schedule"}]}]},{"description":"Oncology (pancreatic cancer), multiplex immonoassay of C5, C4, Cystatin C, factor B, osteoprotegerin, gelsolin, IGFBP3, CA125 and multiplex electrochemiluminescent immunoassay for CA19-9, serum, diagn ","code_information":[{"code":"0342U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":897.000,"maximum":1076.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":914.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1076.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":914.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1076.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":923.910,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":897.000,"methodology":"fee schedule"}]}]},{"description":"Level 2 ENT Procedures ","code_information":[{"code":"05162","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":512.450,"maximum":512.450,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":512.450,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism, psychiatry (ev major depressive disorder, general anxiety disorder, ADHD, schizophrenia), whole blood buccal swab, and pharmacogenomic genotyping of 14 genes and CYP2D6 copy number va ","code_information":[{"code":"0477U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":416.780,"maximum":429.280,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":416.780,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":429.280,"methodology":"fee schedule"}]}]},{"description":"Ureterorrhaphy, suture of ureter (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"50900","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Injection, interferon beta-1a, 1 mcg for subcutaneous use ","code_information":[{"code":"892","type":"RC"},{"code":"Q3028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":80.420,"maximum":80.420,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":80.420,"methodology":"fee schedule"}]}]},{"description":"Inj, crovalimab-akkz, 10 ","code_information":[{"code":"818","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":551.510,"maximum":579.090,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":557.030,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":568.060,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":579.090,"methodology":"fee 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  IPF","code_information":[{"code":"1001","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1036.790,"maximum":1036.790,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1036.790,"methodology":"fee schedule","additional_payer_notes":"Days 3. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Lengthening of palate, and pharyngeal flap ","code_information":[{"code":"362","type":"RC"},{"code":"42226","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER VASCULAR PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"254","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9889.290,"maximum":10704.900,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":10704.900,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":9889.290,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"324","type":"RC"},{"code":"74175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":589.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":484.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":549.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":484.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":589.280,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); 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less than 5 cm ","code_information":[{"code":"27328","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix ","code_information":[{"code":"57421","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation ","code_information":[{"code":"28546","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair ","code_information":[{"code":"41827","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) ","code_information":[{"code":"359","type":"RC"},{"code":"76705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Excision; ischial bursa ","code_information":[{"code":"27060","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Glossectomy; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"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":"17312","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes ipsilateral il ","code_information":[{"code":"27218","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod ","code_information":[{"code":"26392","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Change of cystostomy tube; simple ","code_information":[{"code":"367","type":"RC"},{"code":"51705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulotomy, midfoot; medial release only (separate procedure) ","code_information":[{"code":"28260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":7807.870,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Dilation of ureter(s) or urethra, radiological supervision and interpretation ","code_information":[{"code":"402","type":"RC"},{"code":"74485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2109.970,"maximum":2109.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2109.970,"methodology":"fee schedule"}]}]},{"description":"Vitamin A ","code_information":[{"code":"302","type":"RC"},{"code":"84590","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.610,"maximum":13.930,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.930,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.960,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.610,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, eyelids ","code_information":[{"code":"490","type":"RC"},{"code":"67999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (mr) guidance ","code_information":[{"code":"369","type":"RC"},{"code":"C9734","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transection or avulsion of; infraorbital nerve ","code_information":[{"code":"64734","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Open treatment of radial shaft fracture, includes internal fixation, when performed ","code_information":[{"code":"25515","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm ","code_information":[{"code":"12018","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair medial collateral ligament, elbow, with local tissue ","code_information":[{"code":"24345","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Ureterectomy, with bladder cuff (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"50650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cholinesterase; RBC ","code_information":[{"code":"307","type":"RC"},{"code":"82482","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.810,"maximum":11.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11.770,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.810,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.100,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.810,"methodology":"fee schedule"}]}]},{"description":"Mechanical fragility, RBC, shear stress and spectral analysis profiling ","code_information":[{"code":"0123U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":357.630,"maximum":429.160,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":364.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":429.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":364.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":429.160,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":357.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":368.360,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":357.630,"methodology":"fee schedule"}]}]},{"description":"Proton treatment delivery; simple, without compensation ","code_information":[{"code":"320","type":"RC"},{"code":"77520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.820,"maximum":595.820,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":595.820,"methodology":"fee schedule"}]}]},{"description":"Thyroid imaging (including vascular flow, when performed); ","code_information":[{"code":"351","type":"RC"},{"code":"78013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Open treatment of medial malleolus fracture, includes internal fixation, when performed ","code_information":[{"code":"27766","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Homovanillic acid (HVA) ","code_information":[{"code":"319","type":"RC"},{"code":"83150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.410,"maximum":23.080,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.080,"methodology":"fee schedule"}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube ","code_information":[{"code":"44373","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart ","code_information":[{"code":"310","type":"RC"},{"code":"87084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.070,"maximum":27.880,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.070,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.880,"methodology":"fee schedule"}]}]},{"description":"Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling ","code_information":[{"code":"30469","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Iron stain, peripheral blood ","code_information":[{"code":"319","type":"RC"},{"code":"85536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.880,"maximum":7.090,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.090,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) ","code_information":[{"code":"360","type":"RC"},{"code":"36012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach ","code_information":[{"code":"50660","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION  IPF","code_information":[{"code":"124","type":"RC"},{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":973.680,"maximum":1080.780,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":973.680,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1032.100,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":973.680,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1080.780,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1022.360,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":973.680,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1080.780,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1080.780,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination ","code_information":[{"code":"43231","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"49250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg ","code_information":[{"code":"J1561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":46.900,"maximum":125.810,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":58.490,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":54.810,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":125.810,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":46.900,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":123.240,"methodology":"fee schedule"}]}]},{"description":"Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies ","code_information":[{"code":"892","type":"RC"},{"code":"L8607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":103.820,"maximum":103.820,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":103.820,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty wi ","code_information":[{"code":"480","type":"RC"},{"code":"C9765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":10376.500,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"}]}]},{"description":"MEDIASTINOSCOPY INCL BIOPSY ","code_information":[{"code":"360","type":"RC"},{"code":"39400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy; ulna ","code_information":[{"code":"25360","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous ","code_information":[{"code":"361","type":"RC"},{"code":"49405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Amputation, forearm, through radius and ulna; re-amputation ","code_information":[{"code":"25909","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"63621","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Lung transplant, single; with cardiopulmonary bypass ","code_information":[{"code":"32852","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Selective enzymatic debridement, partial-thickness and/or full-thickness burn eschar, requiring anesthesia (ie, general anesthesia, moderate sedation), including patient monitoring, scalp, neck, hands ","code_information":[{"code":"0975T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7234.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified health care ","code_information":[{"code":"402","type":"RC"},{"code":"76017","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":248.970,"maximum":248.970,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"Lymphangiotomy or other operations on lymphatic channels ","code_information":[{"code":"38308","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or corona ","code_information":[{"code":"37236","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":24120.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9614.870,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10907.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9614.870,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11695.400,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Insertion of intra-aortic balloon assist device through the ascending aorta ","code_information":[{"code":"33973","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the same vessel(s), when perform ","code_information":[{"code":"361","type":"RC"},{"code":"C9764","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar ","code_information":[{"code":"63267","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts ","code_information":[{"code":"33536","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure ","code_information":[{"code":"11005","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Biopsy thyroid, percutaneous core needle ","code_information":[{"code":"361","type":"RC"},{"code":"60100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Venous thrombosis imaging, venogram; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds ","code_information":[{"code":"K0821","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":478.480,"maximum":517.940,"payers_information":[{"payer_name":"Aetna 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rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requir ","code_information":[{"code":"499","type":"RC"},{"code":"66982","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneu ","code_information":[{"code":"37284","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":19440.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Ophthalmic ultrasound, diagnostic; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"}]}]},{"description":"Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip ","code_information":[{"code":"27822","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage, bursa, foot ","code_information":[{"code":"28001","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous ","code_information":[{"code":"481","type":"RC"},{"code":"67027","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":26334.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Fibrinolytic factors and inhibitors; plasminogen, except antigenic assay ","code_information":[{"code":"301","type":"RC"},{"code":"85420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.530,"maximum":7.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7.840,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.730,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6.530,"methodology":"fee schedule"}]}]},{"description":"Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"77054","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":32.380,"maximum":39.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":36.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39.380,"methodology":"fee schedule"}]}]},{"description":"Venography, caval, superior, with serialography, radiological supervision and interpretation ","code_information":[{"code":"612","type":"RC"},{"code":"75827","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1600.040,"maximum":1600.040,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1600.040,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC ","code_information":[{"code":"203","type":"RC"},{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass ","code_information":[{"code":"33255","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cm ","code_information":[{"code":"21557","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of calcaneal fracture, with manipulation ","code_information":[{"code":"28406","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ligation or biopsy, temporal artery ","code_information":[{"code":"37609","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) ","code_information":[{"code":"19306","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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 DELIVERY WITH STERILIZATION AND/OR D&C WITH CC ","code_information":[{"code":"114","type":"RC"},{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 3+. "}]}]},{"description":"Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and ","code_information":[{"code":"490","type":"RC"},{"code":"93622","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":36180.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7591.060,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":8611.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7591.060,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9233.710,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":36180.000,"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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Refilling and maintenance of portable pump ","code_information":[{"code":"824771","type":"CDM"},{"code":"96521","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":529.820,"maximum":540.860,"gross_charge":1276.50,"discounted_cash":1276.50,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"POS","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"PPO","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":24.69,"standard_charge_algorithm":"Reimbursement will be 24.69% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":540.860,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":529.820,"methodology":"fee schedule"}]}]},{"description":"Total repair, truncus arteriosus (Rastelli type operation) ","code_information":[{"code":"33786","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Ciliary body destruction; diathermy ","code_information":[{"code":"66700","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less ","code_information":[{"code":"11440","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); with orbital exenteration ","code_information":[{"code":"361","type":"RC"},{"code":"61585","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT ","code_information":[{"code":"1772","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":10171.340,"maximum":10374.770,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":10171.340,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":10374.770,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":10171.340,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":10171.340,"methodology":"fee schedule"}]}]},{"description":"Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture ","code_information":[{"code":"0544T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Injection, lovotibeglogene autotemcel, per treatment ","code_information":[{"code":"343","type":"RC"},{"code":"J3394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5366638.330,"maximum":5366638.330,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5366638.330,"methodology":"fee schedule"}]}]},{"description":"Sperm isolation; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) ","code_information":[{"code":"58110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping ","code_information":[{"code":"0264U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1263.530,"maximum":1516.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1288.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1516.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1288.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1516.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1263.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1301.440,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1263.530,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypo ","code_information":[{"code":"35103","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous transcatheter implantation of interatrial septal shunt device, including right and left heart catheterization, intracardiac echocardiography, and imaging guidance by the proceduralist, wh ","code_information":[{"code":"0613T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Inj lenacapavir (hiv tx) ","code_information":[{"code":"09155","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":21.630,"maximum":21.630,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":21.630,"methodology":"fee schedule"}]}]},{"description":"Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular ","code_information":[{"code":"33236","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":40210.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Aortography, thoracic, without serialography, radiological supervision and interpretation ","code_information":[{"code":"342","type":"RC"},{"code":"75600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3241.930,"maximum":3241.930,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3241.930,"methodology":"fee schedule"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur ","code_information":[{"code":"27187","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material ","code_information":[{"code":"72148","type":"CPT"},{"code":"802890","type":"CDM"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":607.860,"maximum":620.530,"gross_charge":6667.50,"discounted_cash":6667.50,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":620.530,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":607.860,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH CC ","code_information":[{"code":"0D764DZ","type":"ICD"},{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17085.000,"maximum":17085.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17085.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical ","code_information":[{"code":"63275","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":12227.700,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap) ","code_information":[{"code":"15731","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Replacement, irrigation or revision of lumbosubarachnoid shunt ","code_information":[{"code":"362","type":"RC"},{"code":"63744","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tracheoplasty; tracheopharyngeal fistulization, each stage ","code_information":[{"code":"31755","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of ureteral calculus ","code_information":[{"code":"499","type":"RC"},{"code":"52330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Labyrinthectomy; transcanal ","code_information":[{"code":"69905","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Hepatitis C antibody; confirmatory test (eg, immunoblot) ","code_information":[{"code":"301","type":"RC"},{"code":"86804","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.490,"maximum":18.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":18.590,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":18.590,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.490,"methodology":"fee schedule"}]}]},{"description":"Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use ","code_information":[{"code":"892","type":"RC"},{"code":"90733","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":147.690,"maximum":147.690,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":147.690,"methodology":"fee schedule"}]}]},{"description":"MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT ","code_information":[{"code":"19324","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10520.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator ","code_information":[{"code":"31527","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Clotting inhibitors or anticoagulants; protein C, antigen ","code_information":[{"code":"302","type":"RC"},{"code":"85302","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.010,"maximum":14.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.410,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.010,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.010,"methodology":"fee schedule"}]}]},{"description":"Drainage of perivesical or prevesical space abscess ","code_information":[{"code":"51080","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) ","code_information":[{"code":"21194","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":14439.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":14439.000,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":14144.320,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC One Day Stay","code_information":[{"code":"097","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical ","code_information":[{"code":"480","type":"RC"},{"code":"63304","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12227.700,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Red cell antigen (Indian blood group) genotyping (IN), gene analysis CD44 (CD44 molecule) exons 2, 3, 6 ","code_information":[{"code":"0191U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":274.830,"maximum":283.070,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":283.070,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (H blood group) genotyping (FUT2), gene analysis, FUT2 (fycosyltransferase 2) exon 2 ","code_information":[{"code":"0186U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":185.200,"maximum":222.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":190.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"Insertion, subcutaneous cardiac rhythm monitor, including programming ","code_information":[{"code":"33285","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), urine, quantitative ","code_information":[{"code":"0025U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":85.770,"maximum":117.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":87.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":102.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":87.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":102.920,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":114.430,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":117.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":85.770,"methodology":"fee schedule"}]}]},{"description":"Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal ","code_information":[{"code":"43845","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump ","code_information":[{"code":"96416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":834.110,"maximum":851.480,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"POS","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"PPO","standard_charge_percentage":32.90,"standard_charge_algorithm":"Reimbursement will be 32.9% 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":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":24.69,"standard_charge_algorithm":"Reimbursement will be 24.69% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":851.480,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":834.110,"methodology":"fee schedule"}]}]},{"description":"CEP72 (centrosomal protein, 72-Kda) NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) gene analysis, conmmon variants ","code_information":[{"code":"0286U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":134.130,"maximum":138.150,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":134.130,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":138.150,"methodology":"fee schedule"}]}]},{"description":"Colectomy, partial; with coloproctostomy (low pelvic anastomosis) ","code_information":[{"code":"361","type":"RC"},{"code":"44145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; ","code_information":[{"code":"67880","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"CYSTOSCOPY, RESECT DUCTS ","code_information":[{"code":"52347","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Collection of venous blood by venipuncture ","code_information":[{"code":"310","type":"RC"},{"code":"36415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.340,"maximum":9.620,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.340,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.620,"methodology":"fee schedule"}]}]},{"description":"Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery ","code_information":[{"code":"45308","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Radiologic examination, abdomen; 1 view ","code_information":[{"code":"359","type":"RC"},{"code":"74018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Cystotomy; for simple excision of vesical neck (separate procedure) ","code_information":[{"code":"51520","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy ","code_information":[{"code":"50974","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hereditary colon cancer-related disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel, 5 or more genes, interrogati 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procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and ","code_information":[{"code":"324","type":"RC"},{"code":"77300","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 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","code_information":[{"code":"490","type":"RC"},{"code":"50750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, requiring hospitalization ","code_information":[{"code":"42971","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) ","code_information":[{"code":"21235","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; tumor cell depletion ","code_information":[{"code":"38211","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Percutaneous pulmonary artery revascularization by stent placement, initial; abnormal connections, unilateral ","code_information":[{"code":"33902","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":26334.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) ","code_information":[{"code":"20680","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural ","code_information":[{"code":"61600","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Thyroglobulin antibody ","code_information":[{"code":"307","type":"RC"},{"code":"86800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.910,"maximum":19.090,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":16.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":19.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":16.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":19.090,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":15.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":16.390,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":15.910,"methodology":"fee schedule"}]}]},{"description":"Subcutaneous injection of filling material (eg, collagen); over 10.0 cc ","code_information":[{"code":"11954","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reduction of craniomegalic skull (eg, treated hydrocephalus); not requiring bone grafts or cranioplasty ","code_information":[{"code":"62115","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complete cbc, automated (hgb, hct, rbc, wbc, without platelet count) and automated wbc differential count ","code_information":[{"code":"304","type":"RC"},{"code":"G0306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":7.770,"maximum":9.320,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.320,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.770,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":8.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.770,"methodology":"fee schedule"}]}]},{"description":"Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands ","code_information":[{"code":"0490T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7234.080,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Compatibility test each unit; immediate spin technique ","code_information":[{"code":"86920","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":149.160,"maximum":178.990,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":152.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":178.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":152.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":178.990,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":149.160,"methodology":"fee schedule"}]}]},{"description":"Transcortin (cortisol binding globulin) ","code_information":[{"code":"306","type":"RC"},{"code":"84449","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.000,"maximum":21.600,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.600,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.540,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.000,"methodology":"fee schedule"}]}]},{"description":"Neuroplasty and/or transposition; 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orbits, complete, minimum of 4 views ","code_information":[{"code":"352","type":"RC"},{"code":"70200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation ","code_information":[{"code":"28546","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0274U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":608.170,"maximum":729.800,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":614.250,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":638.580,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":626.420,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":620.330,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":638.580,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":638.580,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":638.580,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":729.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":614.250,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":614.250,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":614.250,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":638.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":620.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":608.170,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":620.330,"methodology":"fee schedule"}]}]},{"description":"Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological s ","code_information":[{"code":"369","type":"RC"},{"code":"50694","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12469.000,"maximum":15167.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14144.700,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12469.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15167.100,"methodology":"case rate","additional_payer_notes":"Days 1 - 4. "}]}]},{"description":"Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial ","code_information":[{"code":"27070","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation ","code_information":[{"code":"349","type":"RC"},{"code":"76881","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Release of extensive scar tissue without detaching extraocular muscle (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"67343","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Injection, asparaginase, recombinant, (rylaze), 0.1 mg ","code_information":[{"code":"892","type":"RC"},{"code":"J9021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":92.700,"maximum":92.700,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":92.700,"methodology":"fee schedule"}]}]},{"description":"Ostectomy of sternum, partial ","code_information":[{"code":"21620","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Cholecystography, oral contrast ","code_information":[{"code":"612","type":"RC"},{"code":"74290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"O.R. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Percutaneous aspiration, spinal cord cyst or syrinx ","code_information":[{"code":"369","type":"RC"},{"code":"62268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Infectious agents (Sexually transmitted infection),Chlamydia tracomatic, Neisseria gonorrhoeae,and Trichomonas vaginalis,multiples amplified probe technique,vaginal,endocervical,gynecological specimen ","code_information":[{"code":"0455U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":142.630,"maximum":146.910,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":142.630,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":146.910,"methodology":"fee schedule"}]}]},{"description":"OTHER ORTHOPEDIC; 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for exploration, with or without biopsy ","code_information":[{"code":"67450","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Level 2 Laparoscopy and R ","code_information":[{"code":"5362","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":10108.770,"maximum":10614.210,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":10209.860,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":10412.030,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":10614.210,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":10108.770,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":10614.210,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":10614.210,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10209.860,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":10209.860,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":10209.860,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":10108.770,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":10108.770,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10614.210,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10310.950,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":10108.770,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":10108.770,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":10310.950,"methodology":"fee schedule"}]}]},{"description":"Excision of sublingual gland ","code_information":[{"code":"367","type":"RC"},{"code":"42450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, abdomen, peritoneum and omentum ","code_information":[{"code":"361","type":"RC"},{"code":"49999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Repair of entropion; suture ","code_information":[{"code":"67921","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level ","code_information":[{"code":"0629T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) ","code_information":[{"code":"58110","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Anoplasty, plastic operation for stricture; infant ","code_information":[{"code":"46705","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; aortoceliac or aortomesenteric ","code_information":[{"code":"35531","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, ºeg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities») ","code_information":[{"code":"96116","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":783.080,"maximum":799.400,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":799.400,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":783.080,"methodology":"fee schedule"}]}]},{"description":"Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) i ","code_information":[{"code":"93455","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2508.000,"maximum":10350.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":10350.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":10350.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":10350.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":10350.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":7393.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2950.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":5154.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6240.000,"methodology":"case rate"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":6935.000,"methodology":"case rate"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":3850.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2950.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2950.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material ","code_information":[{"code":"321","type":"RC"},{"code":"70480","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":159.870,"maximum":194.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":159.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":181.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":159.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":194.410,"methodology":"fee schedule"}]}]},{"description":"Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (eg, Norwood procedure) ","code_information":[{"code":"33619","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Release of extensive scar tissue without detaching extraocular muscle (separate procedure) ","code_information":[{"code":"67343","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers ","code_information":[{"code":"37288","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":19440.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Removal of peritoneal-venous shunt ","code_information":[{"code":"481","type":"RC"},{"code":"49429","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant ","code_information":[{"code":"81303","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":120.000,"maximum":144.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":122.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":144.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":122.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":144.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":123.600,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":120.000,"methodology":"fee schedule"}]}]},{"description":"Injection, cyclophosphamide (frindovyx), 5 mg ","code_information":[{"code":"J9072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.780,"maximum":10.270,"payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":10.270,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":8.780,"methodology":"fee schedule"}]}]},{"description":"Intraoperative radiation treatment management ","code_information":[{"code":"321","type":"RC"},{"code":"77469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":370.210,"maximum":497.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":409.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":464.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":409.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":497.630,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":370.210,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (Duffy blood group) genotyping (FY), gene analysis, ACKR1 (atypical chemokine receptor 1) exons 1-2 ","code_information":[{"code":"0187U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":274.830,"maximum":329.800,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":277.580,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":288.570,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":283.070,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":280.330,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":288.570,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":288.570,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":288.570,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":329.800,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":277.580,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":277.580,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":277.580,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":288.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":280.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":274.830,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":280.330,"methodology":"fee schedule"}]}]},{"description":"Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bifemoral prosthesis ","code_information":[{"code":"34832","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Ligation arteries; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of ampulla of Vater ","code_information":[{"code":"369","type":"RC"},{"code":"48148","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion 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","code_information":[{"code":"892","type":"RC"},{"code":"90678","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":631.750,"maximum":631.750,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":631.750,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique ","code_information":[{"code":"312","type":"RC"},{"code":"87591","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":36.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.140,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn ","code_information":[{"code":"31525","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each ","code_information":[{"code":"86008","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.930,"maximum":21.520,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":21.520,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":18.470,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.930,"methodology":"fee schedule"}]}]},{"description":"Excision of malignant tumor of mandible; radical resection ","code_information":[{"code":"21045","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Incision and drainage, perianal abscess, superficial ","code_information":[{"code":"46050","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance, when performed ","code_information":[{"code":"361","type":"RC"},{"code":"64445","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Initial open implantation of baroreflex activation therapy (BAT) modulation system, including lead placement onto the carotid sinus, lead tunnelling, connection to a pulse generator placed in a distan ","code_information":[{"code":"64654","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional 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":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":3719.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. 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If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programmin ","code_information":[{"code":"0266T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":21649.700,"maximum":26334.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"}]}]},{"description":"Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy ","code_information":[{"code":"67101","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Fetal aneuploidy short tandem-repeat comparative analysis, fetal DNA from products of conception, reported as normal, monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental ane ","code_information":[{"code":"0252U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":759.050,"maximum":910.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":774.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":910.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":774.230,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":910.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":781.820,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":759.050,"methodology":"fee schedule"}]}]},{"description":"Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepa ","code_information":[{"code":"367","type":"RC"},{"code":"47144","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of radial head or neck fracture; with manipulation ","code_information":[{"code":"24655","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"AMPUTATION, LOWER EXTREMITY; M > 47.65 ","code_information":[{"code":"148","type":"RC"},{"code":"B1001","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":19794.710,"maximum":21972.130,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20982.390,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19794.710,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":21972.130,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20784.450,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19992.660,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19992.660,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19992.660,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19794.710,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":21972.130,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":21972.130,"methodology":"fee schedule"}]}]},{"description":"Antibody identification, RBC antibodies, each panel for each serum technique ","code_information":[{"code":"309","type":"RC"},{"code":"86870","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":291.260,"maximum":349.510,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":349.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":297.090,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":349.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":291.260,"methodology":"fee schedule"}]}]},{"description":"Perineoplasty, repair of perineum, nonobstetrical (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"56810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State 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","code_information":[{"code":"31505","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, abdomen; 3 or more views ","code_information":[{"code":"329","type":"RC"},{"code":"74021","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":19.120,"maximum":23.250,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.250,"methodology":"fee schedule"}]}]},{"description":"Compatibility test each unit; electronic ","code_information":[{"code":"302","type":"RC"},{"code":"86923","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":149.160,"maximum":178.990,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":152.140,"methodology":"fee 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Ultrasound, elastography; each additional target lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"400","type":"RC"},{"code":"76983","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":37.190,"maximum":45.230,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":37.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":37.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":45.230,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) ","code_information":[{"code":"21194","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Minocycline hydrochloride ","code_information":[{"code":"01853","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2.590,"maximum":2.590,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":2.590,"methodology":"fee schedule"}]}]},{"description":"PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; 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with graft ","code_information":[{"code":"33845","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor, distal phalanx of finger ","code_information":[{"code":"26262","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Incision and drainage of hematoma, seroma or fluid collection ","code_information":[{"code":"10140","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator ","code_information":[{"code":"481","type":"RC"},{"code":"64583","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy ","code_information":[{"code":"56631","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ureteropyelostomy, anastomosis of ureter and renal pelvis ","code_information":[{"code":"369","type":"RC"},{"code":"50740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"72147","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":304.780,"maximum":370.630,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":304.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":345.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":304.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":370.630,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; common carotid-ipsilateral internal carotid ","code_information":[{"code":"35501","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm ","code_information":[{"code":"11302","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chromosome analysis for breakage syndromes; score 100 cells, clastogen stress (eg, diepoxybutane, mitomycin C, ionizing radiation, UV radiation) ","code_information":[{"code":"312","type":"RC"},{"code":"88249","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":173.170,"maximum":207.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":176.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":207.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":176.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":207.800,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":173.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":178.370,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":173.170,"methodology":"fee schedule"}]}]},{"description":"Repair, primary, disrupted ligament, ankle; collateral ","code_information":[{"code":"27695","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING LEAD ONLY ","code_information":[{"code":"0425T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3686.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Punch graft for hair transplant; 1 to 15 punch grafts ","code_information":[{"code":"15775","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial ","code_information":[{"code":"30905","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Trachelectomy (cervicectomy), amputation of cervix (separate procedure) ","code_information":[{"code":"57530","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thoracotomy; with open intrapleural pneumonolysis ","code_information":[{"code":"32124","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":11794.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Venography, renal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"75833","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":109.250,"maximum":132.850,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":109.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":123.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":109.250,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":132.850,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection ","code_information":[{"code":"43254","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infusion or instillation of radioelement solution (includes 3-month follow-up care) ","code_information":[{"code":"614","type":"RC"},{"code":"77750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":270.870,"maximum":270.870,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":270.870,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical therapy, by intra-articular administration ","code_information":[{"code":"320","type":"RC"},{"code":"79440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":136.310,"maximum":230.850,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":136.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":230.850,"methodology":"fee schedule"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"17281","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Amnioplast 2, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"343","type":"RC"},{"code":"Q4335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List ","code_information":[{"code":"360","type":"RC"},{"code":"36227","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Transthoracic insertion of catheter for stent placement with catheter removal and closure (eg, hybrid approach stage 1) ","code_information":[{"code":"33621","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, shoulder area; multiple tendons through same incision ","code_information":[{"code":"23406","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Excision of lesion of tongue with closure; with local tongue flap ","code_information":[{"code":"41114","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; c ","code_information":[{"code":"19297","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stem cells (ie, CD34), total count ","code_information":[{"code":"86367","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":77.780,"maximum":93.340,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":79.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":93.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":79.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":93.340,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":80.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":77.780,"methodology":"fee schedule"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm ","code_information":[{"code":"17264","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Injection, inflectra ","code_information":[{"code":"01847","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":23.490,"maximum":23.490,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":23.490,"methodology":"fee schedule"}]}]},{"description":"TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence ","code_information":[{"code":"305","type":"RC"},{"code":"81351","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":641.850,"maximum":770.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":654.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":770.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":654.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":770.220,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":641.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":661.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":641.850,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1000.720,"maximum":1110.800,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1000.720,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1060.770,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1000.720,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1110.800,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1050.760,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1000.720,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1110.800,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1110.800,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"INTRA-OPERATIVE USE OF KINETIC BALANCE SENSOR FOR IMPLANT STABILITY DURING KNEE REPLACEMENT ARTHROPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ","code_information":[{"code":"0396T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2028.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review an ","code_information":[{"code":"806256","type":"CDM"},{"code":"93283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","gross_charge":491.75,"discounted_cash":491.75,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"NAP","standard_charge_percentage":55.13,"standard_charge_algorithm":"Reimbursement will be 55.13% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":28.80,"standard_charge_algorithm":"Reimbursement will be 28.8% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_percentage":21.58,"standard_charge_algorithm":"Reimbursement will be 21.58% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) ","code_information":[{"code":"28310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2375.000,"maximum":13741.230,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":13741.230,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":2375.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":13460.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":4950.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":2375.000,"methodology":"case rate"}]}]},{"description":"Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells ","code_information":[{"code":"305","type":"RC"},{"code":"88245","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":173.170,"maximum":178.370,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":173.170,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":178.370,"methodology":"fee schedule"}]}]},{"description":"Incision and retrieval of subcutaneous cranial bone graft for cranioplasty (List separately in addition to code for primary procedure) ","code_information":[{"code":"62148","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B (integrin, alpha 2b ºplatelet glycoprotein IIb of IIb/IIIa complex», antigen CD41 ºGPIIb») (eg, neonatal alloimmune thrombocytopenia ºNAIT», post-tr ","code_information":[{"code":"301","type":"RC"},{"code":"81107","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":122.220,"maximum":146.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":124.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":146.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":124.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":146.660,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":122.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":122.220,"methodology":"fee schedule"}]}]},{"description":"Lymphatics and lymph nodes imaging ","code_information":[{"code":"349","type":"RC"},{"code":"78195","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":416.130,"maximum":479.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":416.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":471.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":416.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":479.650,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary ","code_information":[{"code":"33419","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Proton treatment delivery; simple, with compensation ","code_information":[{"code":"612","type":"RC"},{"code":"77522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1313.780,"maximum":1313.780,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1313.780,"methodology":"fee schedule"}]}]},{"description":"Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs ","code_information":[{"code":"95938","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1334.310,"maximum":1362.110,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1362.110,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1334.310,"methodology":"fee schedule"}]}]},{"description":"2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc ","code_information":[{"code":"300","type":"RC"},{"code":"U0002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":51.310,"maximum":61.570,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":52.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":61.570,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":52.340,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":61.570,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":51.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":52.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":51.310,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"324","type":"RC"},{"code":"75635","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":486.240,"maximum":591.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":486.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":551.510,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":486.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":591.280,"methodology":"fee schedule"}]}]},{"description":"Sperm identification from aspiration (other than seminal fluid) ","code_information":[{"code":"305","type":"RC"},{"code":"89257","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.760,"maximum":59.710,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":50.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":59.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":50.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":59.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.760,"methodology":"fee schedule"}]}]},{"description":"Suture of 1 nerve; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Cystotomy; for excision of bladder tumor ","code_information":[{"code":"369","type":"RC"},{"code":"51530","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Fructose, semen ","code_information":[{"code":"301","type":"RC"},{"code":"82757","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.340,"maximum":20.810,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.810,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":17.340,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.340,"methodology":"fee schedule"}]}]},{"description":"CESAREAN SECTION WITHOUT STERILIZATION WITH MCC ","code_information":[{"code":"132","type":"RC"},{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":2399.790,"maximum":2919.100,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":2722.310,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2399.790,"methodology":"per diem","additional_payer_notes":"Days 5+. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":2919.100,"methodology":"per diem","additional_payer_notes":"Days 5+. "}]}]},{"description":"Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score ","code_information":[{"code":"319","type":"RC"},{"code":"81493","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1050.000,"maximum":1081.500,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1050.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1081.500,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver ","code_information":[{"code":"64590","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":46230.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":36765.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39422.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12005.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":4337.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":46230.000,"methodology":"case rate"}]}]},{"description":"Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier ","code_information":[{"code":"0006M","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":135.000,"maximum":180.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":135.000,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":151.500,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":135.000,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":135.000,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":135.000,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":135.000,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":157.500,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":154.500,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":153.000,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":157.500,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":150.000,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":157.500,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":157.500,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":180.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":151.500,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":151.500,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":151.500,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":150.000,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":150.000,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":157.500,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":153.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":150.000,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":150.000,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":153.000,"methodology":"fee schedule"}]}]},{"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":"50553","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Simpligraft, per square centimeter (add-on, list separately in addition to primary procedure) ","code_information":[{"code":"344","type":"RC"},{"code":"Q4340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.780,"maximum":209.780,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":209.780,"methodology":"fee schedule"}]}]},{"description":"Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter ","code_information":[{"code":"61215","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":42191.600,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":34686.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":39347.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":34686.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42191.600,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11055.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Removal of lung, other than pneumonectomy; with resection-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any p ","code_information":[{"code":"32491","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tacrolimus injection ","code_information":[{"code":"09006","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":254.580,"maximum":254.580,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":254.580,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Ehrlichia chaffeensis, amplified probe technique ","code_information":[{"code":"310","type":"RC"},{"code":"87484","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":36.140,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.140,"methodology":"fee schedule"}]}]},{"description":"Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment ","code_information":[{"code":"369","type":"RC"},{"code":"G0339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10560.000,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC ","code_information":[{"code":"0D164K9","type":"ICD"},{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17085.000,"maximum":17085.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17085.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "}]}]},{"description":"Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) ","code_information":[{"code":"360","type":"RC"},{"code":"58120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1041.650,"maximum":1041.650,"payers_information":[{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":1041.650,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; ","code_information":[{"code":"301","type":"RC"},{"code":"89050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.720,"maximum":5.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.810,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.660,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.720,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.860,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.720,"methodology":"fee schedule"}]}]},{"description":"Removal of a total replacement heart system (artificial heart) for heart transplantation (List separately in addition to code for primary procedure) ","code_information":[{"code":"33929","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Complement fixation tests, each antigen ","code_information":[{"code":"306","type":"RC"},{"code":"86171","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.010,"maximum":12.010,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":12.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12.010,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10.010,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10.010,"methodology":"fee schedule"}]}]},{"description":"Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator ","code_information":[{"code":"0787T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9391.200,"maximum":25088.950,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":23016.870,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":10236.240,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":23016.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":23016.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":23016.870,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":16440.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20625.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":23397.570,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":10438.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20625.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25088.950,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":12668.610,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":10337.590,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":10337.590,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":11640.450,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":10540.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12521.600,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":10540.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":9391.200,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10236.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":10236.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":10236.240,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":10134.890,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":10540.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11221.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":11402.890,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":10540.290,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":10641.630,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10550.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9922.060,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":10134.890,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":10134.890,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":10337.590,"methodology":"fee schedule"}]}]},{"description":"Phalangectomy, toe, each toe ","code_information":[{"code":"28150","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of nasoethmoid fracture; with external fixation ","code_information":[{"code":"21339","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Resection, humeral head ","code_information":[{"code":"23195","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component ","code_information":[{"code":"23473","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DEPRESSIVE NEUROSES  IPF","code_information":[{"code":"1001","type":"RC"},{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1012.990,"maximum":1012.990,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1012.990,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, unilater ","code_information":[{"code":"27057","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery ","code_information":[{"code":"37255","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement o ","code_information":[{"code":"481","type":"RC"},{"code":"53448","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance angiography, neck; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Cystorrhaphy, suture of bladder wound, injury or rupture; complicated ","code_information":[{"code":"481","type":"RC"},{"code":"51865","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, elbow, arthrography, radiological supervision and interpretation ","code_information":[{"code":"340","type":"RC"},{"code":"73085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":367.840,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"}]}]},{"description":"Proctosigmoidoscopy, rigid; 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with excision of carotid artery ","code_information":[{"code":"360","type":"RC"},{"code":"60605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Revision of total elbow arthroplasty, including allograft when performed; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24559.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21649.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26334.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":21676.630,"methodology":"fee schedule","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Sperm identification from aspiration (other than seminal fluid) ","code_information":[{"code":"306","type":"RC"},{"code":"89257","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.760,"maximum":59.710,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":50.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":59.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":50.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":59.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":49.760,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture ","code_information":[{"code":"15920","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":19440.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"}]}]},{"description":"GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence ","code_information":[{"code":"312","type":"RC"},{"code":"81252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":101.120,"maximum":104.150,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":101.120,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":104.150,"methodology":"fee schedule"}]}]},{"description":"PERSONALITY DISORDERS ","code_information":[{"code":"7521","type":"APR-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1545.010,"maximum":1575.910,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":1545.010,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":1575.910,"methodology":"fee schedule"},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1545.010,"methodology":"fee schedule"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1545.010,"methodology":"fee schedule"}]}]},{"description":"Otoplasty, protruding ear, with or without size reduction ","code_information":[{"code":"69300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":8193.780,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":8193.780,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8026.560,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm ","code_information":[{"code":"11623","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal serum, combined with clin ","code_information":[{"code":"0247U","type":"CPT"},{"code":"319","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":750.000,"maximum":772.500,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":750.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":772.500,"methodology":"fee schedule"}]}]},{"description":"Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); complicated, requiring hospitalization ","code_information":[{"code":"362","type":"RC"},{"code":"42961","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INCISION AND DRAINAGE OF SOFT TISSUE ABSCESS, SUBFASCIAL (IE, INVOLVES THE SOFT TISSUE BELOW THE DEEP FASCIA) ","code_information":[{"code":"20005","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Diagnostic bone marrow; aspiration(s) ","code_information":[{"code":"367","type":"RC"},{"code":"38220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection ","code_information":[{"code":"38550","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"FLT3 (fms-related tyrosine kinase 3) (eg, acute lyeloid leukemia) internal tandem duplication (ITD) variants, quantitative ","code_information":[{"code":"0046U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":407.430,"maximum":488.920,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":415.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":488.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":415.580,"methodology":"fee 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Exchange nephrostomy catheter, percutaneous, with ureteral stricture balloon dilation, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or flu ","code_information":[{"code":"750","type":"RC"},{"code":"C7548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7365.500,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging ","code_information":[{"code":"320","type":"RC"},{"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":394.990,"maximum":480.320,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":394.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":448.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":394.990,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":480.320,"methodology":"fee schedule"}]}]},{"description":"3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; req ","code_information":[{"code":"323","type":"RC"},{"code":"76377","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":67.110,"maximum":81.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":67.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":76.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":67.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":81.610,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE O.R. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) ","code_information":[{"code":"26862","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Computed tomography, thoracic spine; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"72128","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":251.390,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":206.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":234.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":206.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":251.390,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":149.130,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Indium in-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries ","code_information":[{"code":"344","type":"RC"},{"code":"A9507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2854.980,"maximum":2854.980,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2854.980,"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage) ","code_information":[{"code":"0538T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5947.170,"maximum":7234.080,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"}]}]},{"description":"Clotting; factor VIII related antigen ","code_information":[{"code":"309","type":"RC"},{"code":"85244","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.420,"maximum":24.500,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":20.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.500,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":20.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":24.500,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.420,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.030,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":20.420,"methodology":"fee schedule"}]}]},{"description":"HAND PROCEDURES FOR INJURIES ","code_information":[{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":450.000,"maximum":4523.000,"payers_information":[{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":450.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1671.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":995.000,"methodology":"per diem","additional_payer_notes":"Days 3+. "},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4523.000,"methodology":"per diem","additional_payer_notes":"Days 3+.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; tibioperoneal trunk artery ","code_information":[{"code":"35304","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Arthroscopy, knee, surgical; with lateral release ","code_information":[{"code":"29873","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or sphincteroplasty ","code_information":[{"code":"47420","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"615","type":"RC"},{"code":"74270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial ","code_information":[{"code":"21248","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Chemodenervation of trunk muscle(s); 6 or more muscles ","code_information":[{"code":"64647","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) ","code_information":[{"code":"25066","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach ","code_information":[{"code":"33362","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"Implantation of nerve end into bone or muscle (List separately in addition to neuroma excision) ","code_information":[{"code":"64787","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of coccygeal fracture ","code_information":[{"code":"27200","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter ","code_information":[{"code":"481","type":"RC"},{"code":"50396","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"}]}]},{"description":"Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed ","code_information":[{"code":"44157","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; aortoceliac or aortomesenteric ","code_information":[{"code":"35531","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection and anastomosis ","code_information":[{"code":"361","type":"RC"},{"code":"44227","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10979.300,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Culture, typing; immunofluorescent method, each antiserum ","code_information":[{"code":"303","type":"RC"},{"code":"87140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.570,"maximum":6.680,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.680,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.680,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.570,"methodology":"fee schedule"}]}]},{"description":"Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft ","code_information":[{"code":"21193","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thoracostomy; with rib resection for empyema ","code_information":[{"code":"32035","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, ot ","code_information":[{"code":"360","type":"RC"},{"code":"37242","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":11386.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11386.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":5263.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State 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logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Washed red blood cells un ","code_information":[{"code":"09518","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":357.520,"maximum":357.520,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":357.520,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, lower extremity; with contrast material(s) ","code_information":[{"code":"342","type":"RC"},{"code":"73701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; superficial femoral artery ","code_information":[{"code":"35302","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, phentolamine) ","code_information":[{"code":"490","type":"RC"},{"code":"54231","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Sickle cell disease, microfluidic flow adhesion (P-Selectin), whole blood ","code_information":[{"code":"0122U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":526.230,"maximum":631.480,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":536.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":631.480,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":536.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":631.480,"methodology":"fee 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","code_information":[{"code":"31573","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Colposcopy of the vulva; ","code_information":[{"code":"56820","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Lysis of adhesions (salpingolysis, ovariolysis) ","code_information":[{"code":"58740","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Drainage of abscess; submaxillary, external ","code_information":[{"code":"360","type":"RC"},{"code":"42320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Embolectomy or thrombectomy, with or without catheter; axillary, brachial, innominate, subclavian artery, by arm incision ","code_information":[{"code":"34101","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Radiologic examination, wrist, arthrography, radiological supervision and interpretation ","code_information":[{"code":"342","type":"RC"},{"code":"73115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":367.840,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"}]}]},{"description":"Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula ","code_information":[{"code":"32906","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vesiculectomy, any approach ","code_information":[{"code":"490","type":"RC"},{"code":"55650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant ","code_information":[{"code":"307","type":"RC"},{"code":"81258","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":375.250,"maximum":450.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":382.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":450.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":382.750,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":450.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":375.250,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":386.510,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":375.250,"methodology":"fee schedule"}]}]},{"description":"Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, pa ","code_information":[{"code":"817339","type":"CDM"},{"code":"88309","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":214.290,"maximum":220.590,"gross_charge":5169.00,"discounted_cash":5169.00,"payers_information":[{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":220.590,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":214.290,"methodology":"fee schedule"}]}]},{"description":"Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed ","code_information":[{"code":"323","type":"RC"},{"code":"77067","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":147.080,"maximum":178.860,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":147.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":166.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":147.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":178.860,"methodology":"fee schedule"}]}]},{"description":"Repair of component(s) of a multi-component, inflatable penile prosthesis ","code_information":[{"code":"481","type":"RC"},{"code":"54408","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Temporomandibular joint arthrography, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"70332","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":38.620,"maximum":46.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":38.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":43.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":38.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":46.960,"methodology":"fee schedule"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypo ","code_information":[{"code":"35103","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Decompression; unspecified nerve(s) (specify) ","code_information":[{"code":"480","type":"RC"},{"code":"64722","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ultrasound, infant hips, real time with imaging documentation; limited, static (not requiring physician or other qualified health care professional manipulation) ","code_information":[{"code":"351","type":"RC"},{"code":"76886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, nerve(s) and accompanying structures throughout their entire anatomic course in one extremity, comprehensive, including real-time cine imaging with image documentation, per extremity ","code_information":[{"code":"329","type":"RC"},{"code":"76883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"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":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC ","code_information":[{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13728.000,"maximum":113765.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":91012.210,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":35335.290,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":91012.210,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":91012.210,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":91012.210,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":65008.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":81557.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":92517.580,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":36035.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":81557.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":99205.550,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":43731.800,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":69846.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":69846.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":69846.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":35685.150,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":35685.150,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":45414.050,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":36384.860,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":49512.320,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":36384.860,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":37134.240,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":35335.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":35335.290,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":35335.290,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":34985.440,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":36384.860,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":44487.240,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":36384.860,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 1. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":36734.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":113765.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 10. "},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":34250.750,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":34985.440,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":34985.440,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":35685.150,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneous ","code_information":[{"code":"24357","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":7807.870,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":7807.870,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":7648.520,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Intracavitary radiation source application; intermediate ","code_information":[{"code":"403","type":"RC"},{"code":"77762","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":595.820,"maximum":595.820,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":595.820,"methodology":"fee schedule"}]}]},{"description":"Cardiovascular disease, plasma, analysis of protein biomarkers by aptamer-based microarray and algorithm reported as 4-year likelihood of coronary event in high-risk populations ","code_information":[{"code":"0019M","type":"CPT"},{"code":"311","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":712.400,"maximum":733.770,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":712.400,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":733.770,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing ","code_information":[{"code":"362","type":"RC"},{"code":"93640","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":9657.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation ","code_information":[{"code":"27536","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"114","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1041.650,"maximum":1156.240,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":1041.650,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1104.150,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1041.650,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":1156.240,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":1093.740,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1041.650,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1156.240,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1156.240,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (List separately in additi ","code_information":[{"code":"10036","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; ","code_information":[{"code":"28104","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Strapping; hand or finger ","code_information":[{"code":"29280","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tendon sheath incision (eg, for trigger finger) ","code_information":[{"code":"26055","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood) ","code_information":[{"code":"26952","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","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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superficial, includes autograft, when performed ","code_information":[{"code":"27065","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of baroreflex activation therapy (BAT) modulation system; lead only ","code_information":[{"code":"64658","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, facial bones; 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"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"Iron ","code_information":[{"code":"311","type":"RC"},{"code":"83540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.470,"maximum":6.660,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":6.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":6.660,"methodology":"fee schedule"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation ","code_information":[{"code":"321","type":"RC"},{"code":"76813","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":132.090,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":132.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; 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6 years and older without congenital cardiac anomaly ","code_information":[{"code":"33017","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Organic acid, single, quantitative ","code_information":[{"code":"306","type":"RC"},{"code":"83921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.210,"maximum":25.450,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":25.450,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.210,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":21.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":21.210,"methodology":"fee schedule"}]}]},{"description":"REPLACEMENT OF LOWER EXT JOINT; M > 28.65 & M < 37 ","code_information":[{"code":"024","type":"RC"},{"code":"D0804","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20358.480,"maximum":20358.480,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20358.480,"methodology":"fee schedule"}]}]},{"description":"Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesionºs») ","code_information":[{"code":"21048","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) ","code_information":[{"code":"367","type":"RC"},{"code":"61782","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, maxillofacial area; with contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"70487","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":174.950,"maximum":292.610,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":240.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":272.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":240.630,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":292.610,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":174.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views ","code_information":[{"code":"329","type":"RC"},{"code":"71101","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":46.770,"maximum":56.870,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":46.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":53.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":46.770,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":56.870,"methodology":"fee schedule"}]}]},{"description":"Excision tracheal stenosis and anastomosis; cervical ","code_information":[{"code":"31780","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants ","code_information":[{"code":"310","type":"RC"},{"code":"81296","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":337.730,"maximum":347.860,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":337.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":347.860,"methodology":"fee schedule"}]}]},{"description":"Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to codeºs» for other technical and ","code_information":[{"code":"319","type":"RC"},{"code":"88155","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.650,"maximum":17.580,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.580,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.650,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.650,"methodology":"fee schedule"}]}]},{"description":"Tick-borne replapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgG ","code_information":[{"code":"0044U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":14.860,"maximum":17.830,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":15.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":17.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":15.160,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":17.830,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":14.860,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":15.310,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":14.860,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC One Day Stay","code_information":[{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":9694.170,"maximum":11791.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10997.000,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9694.170,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11791.900,"methodology":"case rate","additional_payer_notes":"Days 0 - 1. "}]}]},{"description":"MAJOR MULTIPLE TRAUMA,NO BRAIN OR SPINAL CORD INJU ","code_information":[{"code":"024","type":"RC"},{"code":"D1704","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":26010.660,"maximum":26010.660,"payers_information":[{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":26010.660,"methodology":"fee schedule"}]}]},{"description":"Angiography, internal mammary, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75756","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":182.380,"maximum":221.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":182.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":206.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":182.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":221.770,"methodology":"fee schedule"}]}]},{"description":"Removal of ocular implant ","code_information":[{"code":"65175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":9153.950,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":9153.950,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":8967.140,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet ","code_information":[{"code":"15574","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) ","code_information":[{"code":"21244","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES FOR OBESITY WITH MCC ","code_information":[{"code":"0D164JA","type":"ICD"},{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3216.000,"maximum":3216.000,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3216.000,"methodology":"per diem","additional_payer_notes":"Days 4+. "}]}]},{"description":"Insertion of a temporary prostatic urethral stent, including urethral measurement ","code_information":[{"code":"53855","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation ","code_information":[{"code":"352","type":"RC"},{"code":"76813","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each ","code_information":[{"code":"15003","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique ","code_information":[{"code":"305","type":"RC"},{"code":"87529","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.090,"maximum":42.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":35.790,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":42.110,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":35.090,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":36.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":35.090,"methodology":"fee schedule"}]}]},{"description":"Neuro Muscular Dystrophy Dmd Seq Alys Bld/Saliva ","code_information":[{"code":"0218U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2279.000,"maximum":2347.370,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2279.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2347.370,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal shock wave involving musculoskeletal system, not otherwise specified ","code_information":[{"code":"0101T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Disarticulation of hip ","code_information":[{"code":"27295","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":19440.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":19440.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass ","code_information":[{"code":"33256","type":"CPT"},{"code":"367","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2030.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2030.000,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"116","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1211.690,"maximum":1344.970,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":1284.390,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":1211.690,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":1211.690,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":1344.970,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":1344.970,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greater ","code_information":[{"code":"23073","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative ","code_information":[{"code":"312","type":"RC"},{"code":"81278","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":207.310,"maximum":213.530,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":207.310,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":213.530,"methodology":"fee schedule"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur ","code_information":[{"code":"27187","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Lengthening of palate, with island flap ","code_information":[{"code":"42227","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Glucose; tolerance test (GTT), 3 specimens (includes glucose) ","code_information":[{"code":"82951","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12.870,"maximum":15.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.130,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.260,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.870,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm ","code_information":[{"code":"12032","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, diagnostic (separate procedure); 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"61517","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation ","code_information":[{"code":"25680","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) ","code_information":[{"code":"89331","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.770,"maximum":23.510,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":19.790,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":17.630,"methodology":"fee schedule"},{"payer_name":"Aetna Better Health of Georgia","plan_name":"MCD","standard_charge_dollar":20.570,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":20.180,"methodology":"fee schedule"},{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_dollar":19.980,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":20.570,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":19.590,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":20.570,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":20.570,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":23.510,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":19.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":19.790,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":19.790,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":19.590,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":16.770,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":19.590,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":20.570,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":19.590,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":19.590,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":19.980,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) ","code_information":[{"code":"307","type":"RC"},{"code":"81264","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":172.730,"maximum":207.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":176.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":207.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":176.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":207.280,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":172.730,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":177.910,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":172.730,"methodology":"fee schedule"}]}]},{"description":"Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use ","code_information":[{"code":"892","type":"RC"},{"code":"90586","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":270.550,"maximum":270.550,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":270.550,"methodology":"fee schedule"}]}]},{"description":"Embryo transfer, intrauterine ","code_information":[{"code":"58974","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Transcatheter removal or debulking of intracardiac mass (eg, vegetations, thrombus) via suction (eg, vacuum, aspiration) device, percutaneous approach, with intraoperative reinfusion of aspirated bloo ","code_information":[{"code":"0644T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9695.900,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10998.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9695.900,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11794.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"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 u ","code_information":[{"code":"19083","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Ablation, irreversible electroporation, prostate, 1 or more tumors, including imaging guidance, percutaneous ","code_information":[{"code":"55877","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure 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procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Bone marrow harvesting for transplantation; autologous ","code_information":[{"code":"361","type":"RC"},{"code":"38232","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75887","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":97.190,"maximum":118.190,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":97.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":110.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":97.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":118.190,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification ","code_information":[{"code":"304","type":"RC"},{"code":"87592","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.840,"maximum":51.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":51.410,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":51.410,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":42.840,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":44.130,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":42.840,"methodology":"fee schedule"}]}]},{"description":"Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve ","code_information":[{"code":"42425","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Computed tomography, head or brain; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Antibody; Coccidioides ","code_information":[{"code":"300","type":"RC"},{"code":"86635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.470,"maximum":13.760,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":11.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":13.760,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":11.700,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":13.760,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.470,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.810,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":11.470,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; optic foramina ","code_information":[{"code":"350","type":"RC"},{"code":"70190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":90.690,"maximum":90.690,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.690,"methodology":"fee schedule"}]}]},{"description":"Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal) ","code_information":[{"code":"30802","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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planar, whole body, sin ","code_information":[{"code":"321","type":"RC"},{"code":"78802","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":313.840,"maximum":1344.640,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":313.840,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1344.640,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cm ","code_information":[{"code":"27618","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4005.850,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4005.850,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":3924.100,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial ","code_information":[{"code":"499","type":"RC"},{"code":"61650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":9045.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4996.760,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4404.810,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5357.950,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9045.000,"methodology":"case rate"}]}]},{"description":"Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); ","code_information":[{"code":"24586","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; first 25 sq cm or less of harvested skin ","code_information":[{"code":"15013","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5947.170,"maximum":17280.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, adductor of hip, percutaneous (separate procedure) ","code_information":[{"code":"27000","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance, when performed ","code_information":[{"code":"480","type":"RC"},{"code":"64445","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bone and/or joint imaging; limited area ","code_information":[{"code":"402","type":"RC"},{"code":"78300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Proton treatment delivery; intermediate ","code_information":[{"code":"401","type":"RC"},{"code":"77523","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1313.780,"maximum":1313.780,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1313.780,"methodology":"fee schedule"}]}]},{"description":"Angiography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"75716","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":116.730,"maximum":141.950,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":116.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":132.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":116.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":141.950,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences ","code_information":[{"code":"323","type":"RC"},{"code":"74183","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":156.400,"maximum":190.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":156.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":177.390,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":156.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":190.180,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of proximal humerus; ","code_information":[{"code":"23150","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major bronchus stented (List separately in addition to code for primary procedure) ","code_information":[{"code":"31637","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair, dislocating peroneal tendons; with fibular osteotomy ","code_information":[{"code":"27676","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification ","code_information":[{"code":"302","type":"RC"},{"code":"87542","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.760,"maximum":50.110,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":42.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":50.110,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":42.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":50.110,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":41.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":43.010,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":41.760,"methodology":"fee schedule"}]}]},{"description":"Repair blood vessel, direct; intrathoracic, with bypass ","code_information":[{"code":"35211","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sympathectomy; ulnar artery ","code_information":[{"code":"64822","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle ","code_information":[{"code":"23170","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2595.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Removal foreign body from external auditory canal; without general anesthesia ","code_information":[{"code":"69200","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Amputation, thigh, through femur, any level; re-amputation ","code_information":[{"code":"27596","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) ","code_information":[{"code":"45317","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, direct, operative, with biopsy; ","code_information":[{"code":"31535","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander) ","code_information":[{"code":"40527","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"321","type":"RC"},{"code":"72194","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":486.430,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":400.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":453.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":400.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":486.430,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":290.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft ","code_information":[{"code":"15860","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Trypsin; 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M > 0 ","code_information":[{"code":"118","type":"RC"},{"code":"C2101","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":21750.180,"maximum":24142.700,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":23055.190,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":21750.180,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":24142.700,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":22837.690,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21967.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":21967.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":21967.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":21750.180,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":24142.700,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":24142.700,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, pelvis; complete, minimum of 3 views ","code_information":[{"code":"329","type":"RC"},{"code":"72190","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":19.030,"maximum":23.140,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":21.580,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":23.140,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"73718","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":258.560,"maximum":314.420,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":258.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":293.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":258.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":314.420,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; double-contrast (eg, high-density barium and air via enteroclysis tube) stu ","code_information":[{"code":"350","type":"RC"},{"code":"74251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use ","code_information":[{"code":"82962","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3.280,"maximum":3.940,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3.350,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3.940,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3.380,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.280,"methodology":"fee schedule"}]}]},{"description":"Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion ","code_information":[{"code":"0894T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10979.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":10239.100,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":9026.110,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10979.300,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Balloon dilatation of intracranial vasospasm, percutaneous; 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screen, each antibody ","code_information":[{"code":"312","type":"RC"},{"code":"86403","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.540,"maximum":11.890,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":11.540,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":11.890,"methodology":"fee schedule"}]}]},{"description":"Amiodarone ","code_information":[{"code":"300","type":"RC"},{"code":"80151","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.640,"maximum":22.370,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":19.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.370,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":19.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22.370,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":18.640,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.640,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, wrist; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open ","code_information":[{"code":"24358","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) ","code_information":[{"code":"321","type":"RC"},{"code":"77334","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":93.400,"maximum":113.570,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":93.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":105.930,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":93.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":113.570,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, knee, arthrography, radiological supervision and interpretation ","code_information":[{"code":"614","type":"RC"},{"code":"73580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.840,"maximum":367.840,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":367.840,"methodology":"fee schedule"}]}]},{"description":"PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant ","code_information":[{"code":"305","type":"RC"},{"code":"81308","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":301.350,"maximum":310.390,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":301.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":310.390,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"612","type":"RC"},{"code":"74175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"67025","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Transferrin ","code_information":[{"code":"303","type":"RC"},{"code":"84466","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.760,"maximum":15.310,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":13.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":15.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":13.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15.310,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.760,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13.140,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.760,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when ","code_information":[{"code":"369","type":"RC"},{"code":"37293","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Bone marrow imaging; multiple areas ","code_information":[{"code":"324","type":"RC"},{"code":"78103","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":413.880,"maximum":413.880,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":413.880,"methodology":"fee schedule"}]}]},{"description":"Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular ","code_information":[{"code":"33208","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9657.000,"maximum":40210.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12396.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14062.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12396.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":15079.200,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":9657.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":40210.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":38190.000,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure) ","code_information":[{"code":"31632","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Inst tauro 1.35mg/hep 100 ","code_information":[{"code":"744","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":5.970,"maximum":6.270,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":6.030,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":6.150,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":6.270,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":6.270,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":6.270,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":6.030,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":6.030,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":6.030,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":6.270,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6.090,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":5.970,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":6.090,"methodology":"fee schedule"}]}]},{"description":"Trabecular bone score (TBS), structural condition of the bone microarchitecture; interpretation and report on fracture-risk only by other qualified health care professional ","code_information":[{"code":"322","type":"RC"},{"code":"77092","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.410,"maximum":23.360,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":11.410,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":23.360,"methodology":"fee schedule"}]}]},{"description":"Craniofacial approach to anterior cranial fossa; intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa ","code_information":[{"code":"61583","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Interprofessional telephone/internet/electronic health record assessment and management service provided by a practitioner in a specialty whose covered services are limited by statute to services for ","code_information":[{"code":"G0548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":42.070,"maximum":42.070,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":42.070,"methodology":"fee schedule"}]}]},{"description":"Culture, typing; other methods ","code_information":[{"code":"309","type":"RC"},{"code":"87158","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.740,"maximum":9.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":7.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9.290,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":7.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":9.290,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7.740,"methodology":"fee schedule"}]}]},{"description":"Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin, beta 3 ºplatelet glycoprotein IIIa, antigen CD61» ºGPIIIa») (eg, neonatal alloimmune thrombocytopenia ºNAIT», post-transfusion purpura), ","code_information":[{"code":"81110","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":122.220,"maximum":146.660,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":124.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":146.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":124.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":146.660,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":125.890,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":122.220,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm ","code_information":[{"code":"21011","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2534.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging ","code_information":[{"code":"51798","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","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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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy ","code_information":[{"code":"362","type":"RC"},{"code":"43860","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Medial canthopexy (separate procedure) ","code_information":[{"code":"21280","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Factor xiii anti-hem fact ","code_information":[{"code":"1416","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":10.760,"maximum":11.300,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":10.870,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":11.090,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":11.300,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":10.760,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":11.300,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":11.300,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":10.870,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":10.870,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":10.870,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":10.760,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":10.760,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":11.300,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10.980,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":10.760,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":10.760,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":10.980,"methodology":"fee schedule"}]}]},{"description":"Venography, orbital, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"75880","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed ","code_information":[{"code":"27540","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for pr ","code_information":[{"code":"15847","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantifi ","code_information":[{"code":"340","type":"RC"},{"code":"78483","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":103.910,"maximum":119.770,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":103.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":117.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":103.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":119.770,"methodology":"fee schedule"}]}]},{"description":"Wedging of cast (except clubfoot casts) ","code_information":[{"code":"29740","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of tendon, palm, flexor or extensor, single, each tendon ","code_information":[{"code":"26170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":4098.580,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":4098.580,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":4014.930,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint ","code_information":[{"code":"26520","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Esophagotomy, thoracic approach, with removal of foreign body ","code_information":[{"code":"367","type":"RC"},{"code":"43045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) ","code_information":[{"code":"63295","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), ea ","code_information":[{"code":"31651","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); fibula ","code_information":[{"code":"27641","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) ","code_information":[{"code":"404","type":"RC"},{"code":"78709","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":554.420,"maximum":554.420,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":554.420,"methodology":"fee schedule"}]}]},{"description":"Excision of cervical stump, abdominal approach; ","code_information":[{"code":"57540","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, popliteal ar ","code_information":[{"code":"35151","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Sodium phosphate p-32, therapeutic, per millicurie ","code_information":[{"code":"344","type":"RC"},{"code":"A9563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":459.100,"maximum":459.100,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":459.100,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; 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with removal of foreign body(s) ","code_information":[{"code":"43215","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy, mandible, segmental; ","code_information":[{"code":"21198","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed ","code_information":[{"code":"24635","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Oncology (pancreatic), DNA, whole genome sequencing with 5-hydrosymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected ","code_information":[{"code":"0410U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1160.000,"maximum":1392.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1183.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1392.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1183.200,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1392.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":1160.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":1194.800,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1160.000,"methodology":"fee schedule"}]}]},{"description":"Sickling of RBC, reduction ","code_information":[{"code":"319","type":"RC"},{"code":"85660","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.510,"maximum":5.680,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.510,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.680,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"403","type":"RC"},{"code":"70498","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":183.360,"maximum":183.360,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":183.360,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy, indirect; with vocal cord injection ","code_information":[{"code":"31513","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique ","code_information":[{"code":"310","type":"RC"},{"code":"87650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.050,"maximum":20.650,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":20.050,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":20.650,"methodology":"fee schedule"}]}]},{"description":"IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B-cell), variable region somatic mutation analysis ","code_information":[{"code":"310","type":"RC"},{"code":"81263","type":"CPT"},{"code":"826526","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":294.520,"maximum":303.360,"gross_charge":3924.75,"discounted_cash":3924.75,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":294.520,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":303.360,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed ","code_information":[{"code":"64447","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1741.500,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":1777.780,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":1741.500,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm ","code_information":[{"code":"11646","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Bypass graft; 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drainage of abscess of palate, uvula ","code_information":[{"code":"360","type":"RC"},{"code":"42000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Corticosterone ","code_information":[{"code":"306","type":"RC"},{"code":"82528","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.520,"maximum":27.020,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":22.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":27.020,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":22.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27.020,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.520,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.200,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22.520,"methodology":"fee schedule"}]}]},{"description":"Rolapitant, oral, 1 mg ","code_information":[{"code":"344","type":"RC"},{"code":"J8670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.300,"maximum":3.300,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.300,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, lower extremity; without contrast material ","code_information":[{"code":"402","type":"RC"},{"code":"73700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) ","code_information":[{"code":"36011","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision ","code_information":[{"code":"20150","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10560.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"204","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":827.630,"maximum":827.630,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":827.630,"methodology":"fee schedule","additional_payer_notes":"Days 8. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"}]}]},{"description":"Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at ","code_information":[{"code":"301","type":"RC"},{"code":"81410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":504.000,"maximum":604.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":514.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":604.800,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":514.080,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":604.800,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":504.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":519.120,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":504.000,"methodology":"fee schedule"}]}]},{"description":"Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each ","code_information":[{"code":"28160","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction of mandible or maxilla, subperiosteal implant; partial ","code_information":[{"code":"21245","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation) ","code_information":[{"code":"361","type":"RC"},{"code":"G6018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"von Willebrand factor (VWF), type 2N, factor VIII and VWF binding evaluation, enzyme-linked immunosorbent assays (ELISA), plasma ","code_information":[{"code":"0284U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.270,"maximum":20.720,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":17.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":17.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":20.720,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":17.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17.270,"methodology":"fee schedule"}]}]},{"description":"Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not ","code_information":[{"code":"301","type":"RC"},{"code":"G0482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":198.740,"maximum":238.490,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":202.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":238.490,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":202.710,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":238.490,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":198.740,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":204.700,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":198.740,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; 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unilateral ","code_information":[{"code":"409","type":"RC"},{"code":"70328","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":40.830,"maximum":49.650,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":40.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":46.310,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":40.830,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":49.650,"methodology":"fee schedule"}]}]},{"description":"Level 1 ICD and Similar P ","code_information":[{"code":"5231","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":21153.220,"maximum":22210.880,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":21364.750,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":21787.820,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":22210.880,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":21153.220,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":22210.880,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":22210.880,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":21364.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":21364.750,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":21364.750,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":21153.220,"methodology":"fee schedule"},{"payer_name":"Humana BH","plan_name":"MCR","standard_charge_dollar":21153.220,"methodology":"fee schedule"},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":22210.880,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21576.280,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":21153.220,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":21153.220,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":21576.280,"methodology":"fee schedule"}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; 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Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses ","code_information":[{"code":"0036U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4780.000,"maximum":5736.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4875.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5736.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4875.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5736.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4923.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4780.000,"methodology":"fee schedule"}]}]},{"description":" Continuous Ambulatory Peritoneal Dialysis - Other Outpatient CAPD  ","code_information":[{"code":"849","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":251.000,"maximum":1838.410,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":1511.360,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":1714.480,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":1511.360,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":1838.410,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":251.000,"methodology":"case rate"}]}]},{"description":"Thyroidectomy, total or complete ","code_information":[{"code":"362","type":"RC"},{"code":"60240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination; scapula, complete ","code_information":[{"code":"619","type":"RC"},{"code":"73010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Culture, typing; immunologic method, other than immunofluorescence (eg, agglutination grouping), per antiserum ","code_information":[{"code":"87147","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5.180,"maximum":6.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.280,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.340,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.180,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine; thoracic, 3 views ","code_information":[{"code":"619","type":"RC"},{"code":"72072","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.530,"maximum":109.530,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"}]}]},{"description":"Tiagabine ","code_information":[{"code":"312","type":"RC"},{"code":"80199","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.110,"maximum":27.920,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":27.110,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":27.920,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each ","code_information":[{"code":"26725","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, facial bones; complete, minimum of 3 views ","code_information":[{"code":"324","type":"RC"},{"code":"70150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":74.550,"maximum":245.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":74.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":84.560,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":74.550,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":90.650,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":109.530,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Venography, renal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"75831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":135.500,"maximum":6438.740,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":187.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":212.640,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":187.470,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":227.970,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":135.500,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3241.930,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":6438.740,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with other than vein; aortofemoral ","code_information":[{"code":"35647","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency ","code_information":[{"code":"50592","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele ","code_information":[{"code":"58270","type":"CPT"},{"code":"721","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transluminal dilation of aqueous outflow canal (eg, canaloplasty); with retention of device or stent ","code_information":[{"code":"66175","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Glossectomy; partial, with unilateral radical neck dissection ","code_information":[{"code":"361","type":"RC"},{"code":"41135","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10585.000,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each ","code_information":[{"code":"26725","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid processºes»); with manipulation ","code_information":[{"code":"24675","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Angiography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75716","type":"CPT"},{"code":"806226","type":"CDM"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":137.520,"maximum":167.230,"gross_charge":31433.25,"discounted_cash":31433.25,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":137.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":155.980,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":137.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":167.230,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, upper extremity, with or without contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"73225","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":515.950,"maximum":627.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":515.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":585.210,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":515.950,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":627.400,"methodology":"fee schedule"}]}]},{"description":"Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance ","code_information":[{"code":"20610","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedu ","code_information":[{"code":"44360","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Fine needle aspiration biopsy, including MR guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10012","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, elbow; with synovial biopsy only ","code_information":[{"code":"24100","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"BURNS; M=12-45 ","code_information":[{"code":"118","type":"RC"},{"code":"C2102","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":34465.570,"maximum":38256.790,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":36533.510,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":34465.570,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":38256.790,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":36188.850,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":34810.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":34810.230,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":34810.230,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":34465.570,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":38256.790,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":38256.790,"methodology":"fee schedule"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad ","code_information":[{"code":"15838","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Dexamethasone suppression panel, 48 hour This panel must include the following: Free cortisol, urine (82530 x 2) Cortisol (82533 x 2) Volume measurement for timed collection (81050 x 2) ","code_information":[{"code":"304","type":"RC"},{"code":"80420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":161.880,"maximum":194.260,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":165.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":194.260,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":165.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":194.260,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":161.880,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":166.740,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":161.880,"methodology":"fee schedule"}]}]},{"description":"VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variant(s) (eg, -1639G>A, c.173+1000C>T) ","code_information":[{"code":"302","type":"RC"},{"code":"81355","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":88.200,"maximum":105.840,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":89.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":105.840,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":89.960,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":105.840,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":88.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":90.850,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":88.200,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) ","code_information":[{"code":"27310","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents ","code_information":[{"code":"19371","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2365.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":" Clinic General Classification  ","code_information":[{"code":"510","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_percentage":46.00,"standard_charge_algorithm":"Reimbursement will be 46% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":40.00,"standard_charge_algorithm":"Reimbursement will be 40% of billable gross charges.","median_amount":5459.340,"10th_percentile":863.340,"90th_percentile":5995.730,"count":"1 through 10","methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of this service in the last 15 months prior to posting and may not be statistically significant. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."}]}]},{"description":"Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver ","code_information":[{"code":"47361","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"321","type":"RC"},{"code":"73223","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":153.440,"maximum":186.590,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":153.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":174.040,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":153.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":186.590,"methodology":"fee schedule"}]}]},{"description":"Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy ","code_information":[{"code":"481","type":"RC"},{"code":"64763","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; battery component only ","code_information":[{"code":"0518T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4829.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. 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The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, flexible or rigid telescopic, with stroboscopy ","code_information":[{"code":"31579","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2496.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10008","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1669.000,"maximum":3633.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"}]}]},{"description":"Copper ","code_information":[{"code":"300","type":"RC"},{"code":"82525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.410,"maximum":14.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":12.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":14.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":12.660,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":14.890,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":12.410,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":12.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":12.410,"methodology":"fee schedule"}]}]},{"description":"Protein, total, by refractometry, any source ","code_information":[{"code":"304","type":"RC"},{"code":"84160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.610,"maximum":6.730,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5.720,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":6.730,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":5.610,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":5.780,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5.610,"methodology":"fee schedule"}]}]},{"description":"Transurethral destruction of prostate tissue; 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excision stenosis and anastomosis ","code_information":[{"code":"31775","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2550.000,"maximum":2550.000,"payers_information":[{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Intraoperative radiation treatment delivery, x-ray, single treatment session ","code_information":[{"code":"349","type":"RC"},{"code":"77424","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7873.820,"maximum":7873.820,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7873.820,"methodology":"fee schedule"}]}]},{"description":"ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"300","type":"RC"},{"code":"81183","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":137.000,"maximum":164.400,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":139.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":164.400,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":139.740,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":164.400,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":137.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":141.110,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":137.000,"methodology":"fee schedule"}]}]},{"description":"MAJOR MULTIPLE TRAUMA WITH BRAIN OR SPINAL CORD IN ","code_information":[{"code":"138","type":"RC"},{"code":"A1803","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":20131.360,"maximum":22345.810,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":21339.240,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":20131.360,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":22345.810,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":21137.930,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":20332.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":20332.680,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":20332.680,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":20131.360,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":22345.810,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":22345.810,"methodology":"fee schedule"}]}]},{"description":"Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis ","code_information":[{"code":"43336","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral ","code_information":[{"code":"55300","type":"CPT"},{"code":"723","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use ","code_information":[{"code":"636","type":"RC"},{"code":"90622","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":0.020,"maximum":0.020,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":0.020,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"72195","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":259.100,"maximum":315.070,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":259.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":293.880,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":259.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":315.070,"methodology":"fee schedule"}]}]},{"description":"Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio ","code_information":[{"code":"311","type":"RC"},{"code":"83661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.990,"maximum":22.650,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":21.990,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.650,"methodology":"fee schedule"}]}]},{"description":"Mastoidectomy; modified radical ","code_information":[{"code":"362","type":"RC"},{"code":"69505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, thoracic spine; with contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"72129","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":182.530,"maximum":221.960,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":182.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":207.030,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":182.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":221.960,"methodology":"fee schedule"}]}]},{"description":"Cystatin C ","code_information":[{"code":"82610","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18.520,"maximum":22.220,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":18.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":22.220,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":18.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":22.220,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":19.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":18.520,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH MCC ","code_information":[{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":13500.000,"maximum":60846.960,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":55821.640,"methodology":"fee schedule"},{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":22345.430,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":55821.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":55821.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":55821.640,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":39872.600,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":50022.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56744.940,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":22787.920,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":50022.520,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":60846.960,"methodology":"fee schedule"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":27655.240,"methodology":"fee schedule"},{"payer_name":"Cigna BH ","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":"Clover","plan_name":"MCR","standard_charge_dollar":22566.670,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":22566.670,"methodology":"fee schedule"},{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":28150.780,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":23009.160,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":30368.000,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":23009.160,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":22776.000,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":22345.430,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":22345.430,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":22345.430,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":22124.190,"methodology":"fee schedule"},{"payer_name":"MultiPlan ","plan_name":"Complementary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"MultiPlan ","plan_name":"Primary","standard_charge_percentage":67.30,"standard_charge_algorithm":"Reimbursement will be 67.3% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":23009.160,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"NovaNet","plan_name":"COMM","standard_charge_percentage":90.00,"standard_charge_algorithm":"Reimbursement will be 90% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Office of the Sheriff","plan_name":"COMM","standard_charge_percentage":65.00,"standard_charge_algorithm":"Reimbursement will be 65% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":13728.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 3. "},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":27576.280,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":23009.160,"methodology":"fee schedule","additional_payer_notes":"Days 1 - 7. "},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":23230.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13500.000,"methodology":"case rate","additional_payer_notes":"Days 1 - 2.  If billable gross charges exceed threshold of $388800.00, reimbursement will be $5000 per diem instead of the contracted rate."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21659.580,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":31.60,"standard_charge_algorithm":"Reimbursement will be 31.6% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in the last 15 months prior to posting. Allowed amount values are derived from 835 data and may or may not have been separately reimbursed."},{"payer_name":"United","plan_name":"VACCN","standard_charge_dollar":22124.190,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":22124.190,"methodology":"fee schedule"},{"payer_name":"Wellcare","plan_name":"MCR","standard_charge_dollar":22566.670,"methodology":"fee schedule"}]}]},{"description":"Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord ","code_information":[{"code":"26341","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6746.410,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":5947.170,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7234.080,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison to previously analyzed patient ","code_information":[{"code":"0307U","type":"CPT"},{"code":"314","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":794.490,"maximum":818.320,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":794.490,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":818.320,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay ºEIA», enzyme-linked immunosorbent assay ºELISA», fluorescence immunoassay ºFIA», immunochemiluminometric assay ºIMC ","code_information":[{"code":"309","type":"RC"},{"code":"87420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.910,"maximum":16.690,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":14.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":16.690,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":14.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":16.690,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":13.910,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":14.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":13.910,"methodology":"fee schedule"}]}]},{"description":"Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral ","code_information":[{"code":"27392","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2700.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":7549.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":2700.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":7548.000,"methodology":"case rate"}]}]},{"description":"Histamine ","code_information":[{"code":"301","type":"RC"},{"code":"803520","type":"CDM"},{"code":"83088","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.530,"maximum":35.440,"gross_charge":1420.00,"discounted_cash":1420.00,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":30.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":30.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":35.440,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":29.530,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":30.420,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":29.530,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy, flexible; 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foot, single or multiple tendon(s) (separate procedure) ","code_information":[{"code":"28230","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Amniotic fluid scan (spectrophotometric) ","code_information":[{"code":"310","type":"RC"},{"code":"82143","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.350,"maximum":9.630,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.350,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":9.630,"methodology":"fee schedule"}]}]},{"description":"Blood, l/r, froz/degly/wa ","code_information":[{"code":"09527","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":257.230,"maximum":257.230,"payers_information":[{"payer_name":"Humana","plan_name":"TRICARE","standard_charge_dollar":257.230,"methodology":"fee schedule"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna ","code_information":[{"code":"25491","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"Pulmonary artery embolectomy; with cardiopulmonary bypass ","code_information":[{"code":"33910","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":12621.900,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time ","code_information":[{"code":"322","type":"RC"},{"code":"76000","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":48.300,"maximum":517.790,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":69.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":79.190,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":69.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":84.900,"methodology":"fee schedule"},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":48.300,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":517.790,"methodology":"fee schedule"}]}]},{"description":"Vulvectomy, radical, complete; ","code_information":[{"code":"362","type":"RC"},{"code":"56633","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with vein; axillary-axillary ","code_information":[{"code":"35518","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Malar augmentation, prosthetic material ","code_information":[{"code":"21270","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, selec ","code_information":[{"code":"0239U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3500.000,"maximum":4200.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3570.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4200.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3570.000,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4200.000,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3500.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3605.000,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3500.000,"methodology":"fee schedule"}]}]},{"description":"Macroscopic examination; arthropod ","code_information":[{"code":"307","type":"RC"},{"code":"87168","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.270,"maximum":5.120,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":4.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":5.120,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":4.360,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":5.120,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4.270,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":4.400,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":4.270,"methodology":"fee schedule"}]}]},{"description":"Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to code for primary procedure) ","code_information":[{"code":"306","type":"RC"},{"code":"81426","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2709.950,"maximum":3251.940,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":2764.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":3251.940,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":2764.150,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":3251.940,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2709.950,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":2791.250,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":2709.950,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (H blood group) genotyping (FUT1), gene analysis, FUT1 (fucosyltransferase) exon 4 ","code_information":[{"code":"0185U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":185.200,"maximum":222.240,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":188.900,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":222.240,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":185.200,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":190.760,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":185.200,"methodology":"fee schedule"}]}]},{"description":"Excision of neuroma; hand or foot, except digital nerve ","code_information":[{"code":"362","type":"RC"},{"code":"64782","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"In-situ vein bypass; femoral-popliteal ","code_information":[{"code":"35583","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":10585.000,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixation ","code_information":[{"code":"27227","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Vestibuloplasty; complex (including ridge extension, muscle repositioning) ","code_information":[{"code":"40845","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":10585.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":9871.470,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":8702.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":10585.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); 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complete, minimum of 3 views ","code_information":[{"code":"409","type":"RC"},{"code":"72190","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":50.010,"maximum":60.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":50.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":56.730,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":50.010,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":60.820,"methodology":"fee schedule"}]}]},{"description":"Gastroenterology (irritable bowel disease (IBD), immunoassay for quantitative determination of adalimumab (ADL) levels in venous serum in patients undergoing adalimumab therapy, results reported as a ","code_information":[{"code":"0514U","type":"CPT"},{"code":"310","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":38.570,"maximum":39.730,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":38.570,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":39.730,"methodology":"fee schedule"}]}]},{"description":"Renal allotransplantation, implantation of graft; 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M=12-45 ","code_information":[{"code":"128","type":"RC"},{"code":"B2102","type":"HIPPS"}],"standard_charges":[{"setting":"inpatient","minimum":40995.620,"maximum":45505.140,"payers_information":[{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":43455.360,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":40995.620,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":45505.140,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":43045.400,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":41405.580,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS","standard_charge_dollar":41405.580,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PPO","standard_charge_dollar":41405.580,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MGMCR","standard_charge_dollar":40995.620,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":45505.140,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":45505.140,"methodology":"fee schedule"}]}]},{"description":"Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction of calculus (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"47460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar ","code_information":[{"code":"63287","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction, toe(s); polydactyly ","code_information":[{"code":"28344","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study ","code_information":[{"code":"320","type":"RC"},{"code":"76826","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":172.970,"maximum":248.970,"payers_information":[{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":172.970,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":248.970,"methodology":"fee schedule"}]}]},{"description":"INJECTION, ANESTHETIC AGENT; FACIAL NERVE ","code_information":[{"code":"360","type":"RC"},{"code":"64402","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.000,"maximum":7062.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1116.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal ","code_information":[{"code":"0933T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5045.000,"maximum":10560.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":7062.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":5045.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Reptilase test ","code_information":[{"code":"300","type":"RC"},{"code":"85635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.850,"maximum":11.820,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11.820,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10.050,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":11.820,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":9.850,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":10.150,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":9.850,"methodology":"fee schedule"}]}]},{"description":"Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported ","code_information":[{"code":"0001U","type":"CPT"},{"code":"312","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":720.000,"maximum":741.600,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":720.000,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":741.600,"methodology":"fee schedule"}]}]},{"description":"Special medical radiation physics consultation ","code_information":[{"code":"409","type":"RC"},{"code":"77370","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":136.750,"maximum":136.750,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":136.750,"methodology":"fee schedule"}]}]},{"description":"Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary pr ","code_information":[{"code":"15101","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday 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","code_information":[{"code":"367","type":"RC"},{"code":"59430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed ","code_information":[{"code":"619","type":"RC"},{"code":"77778","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":714.620,"maximum":714.620,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":714.620,"methodology":"fee schedule"}]}]},{"description":"Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guida ","code_information":[{"code":"369","type":"RC"},{"code":"50081","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":12621.900,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Biopsy, muscle; superficial ","code_information":[{"code":"20200","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1230.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Unlisted ophthalmological service or procedure ","code_information":[{"code":"92499","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":61.580,"maximum":62.870,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":62.870,"methodology":"fee schedule"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":61.580,"methodology":"fee schedule"}]}]},{"description":"Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) ","code_information":[{"code":"23552","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":17280.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3686.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":17280.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Enterectomy, resection of small intestine; with enterostomy ","code_information":[{"code":"44125","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Homovanillic acid (HVA) ","code_information":[{"code":"83150","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22.410,"maximum":26.890,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":22.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":26.890,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":22.860,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26.890,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.080,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22.410,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, upper extremity, with or without contrast material(s) ","code_information":[{"code":"322","type":"RC"},{"code":"73225","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":395.780,"maximum":481.280,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":395.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":448.910,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":395.780,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":481.280,"methodology":"fee schedule"}]}]},{"description":"Incision and drainage of vaginal hematoma; obstetrical/postpartum ","code_information":[{"code":"490","type":"RC"},{"code":"57022","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":3633.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":2595.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3224.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1230.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Streptococcus pneumoniae antibody (IgG), serotypes, multiplex immunoassay, quantitative ","code_information":[{"code":"86581","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":92.030,"maximum":110.440,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":93.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":110.440,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":93.870,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":110.440,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":94.790,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":92.030,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ankle, arthrography, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"73615","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.320,"maximum":52.680,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":43.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":49.140,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":43.320,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":52.680,"methodology":"fee schedule"}]}]},{"description":"Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only ","code_information":[{"code":"33995","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy, forearm, with brachial artery exploration ","code_information":[{"code":"24495","type":"CPT"},{"code":"722","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) ","code_information":[{"code":"27310","type":"CPT"},{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":4289.000,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of atrial septal defect and ventricular septal defect, with direct or patch closure ","code_information":[{"code":"33647","type":"CPT"},{"code":"362","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4289.000,"maximum":7512.000,"payers_information":[{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm ","code_information":[{"code":"14041","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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":"pH; body fluid, not otherwise specified ","code_information":[{"code":"300","type":"RC"},{"code":"83986","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.580,"maximum":4.300,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":3.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":4.300,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":3.650,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":4.300,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":3.580,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":3.690,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3.580,"methodology":"fee schedule"}]}]},{"description":"Vulvectomy simple; complete ","code_information":[{"code":"499","type":"RC"},{"code":"56625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1776.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":6868.980,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6055.230,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7365.500,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":4368.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":5508.000,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19») and influe ","code_information":[{"code":"87812","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":74.480,"maximum":89.380,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":75.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":89.380,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":75.970,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":89.380,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":76.710,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":74.480,"methodology":"fee schedule"}]}]},{"description":"Hydroxyproline; free ","code_information":[{"code":"306","type":"RC"},{"code":"83500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.650,"maximum":27.180,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":23.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":27.180,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":23.100,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":27.180,"methodology":"fee schedule"},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.650,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":23.330,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":22.650,"methodology":"fee schedule"}]}]},{"description":"Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary pr ","code_information":[{"code":"15101","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7512.000,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6459.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4613.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":2028.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":1776.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":1669.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Reduction of volvulus, intussusception, internal hernia, by laparotomy ","code_information":[{"code":"369","type":"RC"},{"code":"44050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3415.000,"maximum":7628.330,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"}]}]},{"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":"480","type":"RC"},{"code":"61886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7512.000,"maximum":39422.800,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":36765.200,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":32409.700,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":39422.800,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"}]}]},{"description":"Protein analysis of tissue by Western Blot, with interpretation and report; ","code_information":[{"code":"300","type":"RC"},{"code":"88371","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.230,"maximum":22.900,"payers_information":[{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":22.230,"methodology":"fee schedule"},{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":22.900,"methodology":"fee schedule"}]}]},{"description":"Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation) ","code_information":[{"code":"361","type":"RC"},{"code":"43520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1150.000,"maximum":7628.330,"payers_information":[{"payer_name":"Amerigroup","plan_name":"MCD","standard_charge_dollar":2365.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":7114.080,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":6271.280,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":7628.330,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Peach State ","plan_name":"MGMCD","standard_charge_dollar":1150.000,"methodology":"case rate"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":3415.000,"methodology":"case rate"},{"payer_name":"Wellcare ","plan_name":"MCD","standard_charge_dollar":1150.000,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, lips ","code_information":[{"code":"40799","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":583.970,"maximum":2550.000,"payers_information":[{"payer_name":"Employer's Health Network","plan_name":"WCOMP","standard_charge_dollar":596.130,"methodology":"fee schedule"},{"payer_name":"NHC Advantage","plan_name":"MGMCR","standard_charge_dollar":2550.000,"methodology":"case rate"},{"payer_name":"Prime Health ","plan_name":"WORKERSCOMP","standard_charge_dollar":583.970,"methodology":"fee schedule"},{"payer_name":"Pruitt Health","plan_name":"MCR","standard_charge_dollar":2550.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disrupti ","code_information":[{"code":"33884","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10376.500,"maximum":12621.900,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11771.000,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10376.500,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12621.900,"methodology":"case rate"}]}]},{"description":"Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views ","code_information":[{"code":"329","type":"RC"},{"code":"73522","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":21.620,"maximum":26.290,"payers_information":[{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":21.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":24.530,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":21.620,"methodology":"fee schedule"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":26.290,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow, and wrist, when performed) ","code_information":[{"code":"0349T","type":"CPT"},{"code":"323","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":245.180,"maximum":245.180,"payers_information":[{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":245.180,"methodology":"fee schedule"}]}]},{"description":"Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal ","code_information":[{"code":"44625","type":"CPT"}],"standard_charges":[{"modifiers":"50","modifiers_description":"Bilateral Procedure","setting":"outpatient","payers_information":[{"payer_name":"CareSource","plan_name":"MGMCD","standard_charge_percentage":11.66,"standard_charge_algorithm":"Reimbursement will be 11.66% of billable gross charges.","count":"0","methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of this service in 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, elbow; with membrane (eg, fascial) ","code_information":[{"code":"24360","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3182.000,"maximum":12227.700,"payers_information":[{"payer_name":"Aetna","plan_name":"HMO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"OpenAccess","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_dollar":6761.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Aetna","plan_name":"QualifiedHealthPlan","standard_charge_dollar":4829.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic. The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"BCBS","plan_name":"HIX","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"HMO","standard_charge_dollar":11403.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"Pathway","standard_charge_dollar":10052.400,"methodology":"case rate"},{"payer_name":"BCBS","plan_name":"PPO","standard_charge_dollar":12227.700,"methodology":"case rate"},{"payer_name":"Centurion ","plan_name":"PRISN","standard_charge_dollar":7512.000,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"OAP","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4289.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Friday Health","plan_name":"HIX","standard_charge_dollar":10520.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Health One Alliance","plan_name":"COMMHIX","standard_charge_dollar":3182.000,"methodology":"case rate","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Shared Health","plan_name":"MGMCR","standard_charge_dollar":8970.680,"methodology":"fee schedule","additional_payer_notes":"Additional Notes: The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_dollar":10560.000,"methodology":"case rate"}]}]},{"description":"Intraoperative radiation treatment delivery, electrons, single treatment session ","code_information":[{"code":"400","type":"RC"},{"code":"77425","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7873.820,"maximum":7873.820,"payers_information":[{"payer_name":"Peach State (Ambetter)","plan_name":"HIX","standard_charge_dollar":7873.820,"methodology":"fee schedule"}]}]},{"description":"Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware ","code_information":[{"code":"E2620","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":571.690,"maximum":618.840,"payers_information":[{"payer_name":"Aetna ","plan_name":"MCR","standard_charge_dollar":595.260,"methodology":"fee schedule"},{"payer_name":"BCBS ","plan_name":"MCR","standard_charge_dollar":607.050,"methodology":"fee schedule"},{"payer_name":"Clover","plan_name":"MCR","standard_charge_dollar":618.840,"methodology":"fee schedule"},{"payer_name":"Devoted Health","plan_name":"MCR","standard_charge_dollar":589.370,"methodology":"fee schedule"},{"payer_name":"Eon Health","plan_name":"MCR","standard_charge_dollar":618.840,"methodology":"fee schedule"},{"payer_name":"Georgia Assurance","plan_name":"MCR","standard_charge_dollar":618.840,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"MCRHMO","standard_charge_dollar":595.260,"methodology":"fee schedule"},{"payer_name":"HealthSpring","plan_name":"PFFS"