{"hospital_name":"PLAISTOW FSER","last_updated_on":"2025-11-01","version":"2.2.0","affirmation":{"affirmation":"To the best of its knowledge and belief, the 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 indicated.","confirm_affirmation":true},"hospital_location":["PLAISTOW FSER"],"hospital_address":["26 PLAISTOW RD, PLAISTOW, NH, 03865"],"license_information":{"hospital_license_number":"4699","state":"NH"},"standard_charge_information":[{"description":"Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal ","code_information":[{"code":"369","type":"RC"},{"code":"50325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed ","code_information":[{"code":"304","type":"RC"},{"code":"81465","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1539.72,"maximum":3650.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1539.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3597.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3650.40,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT ","code_information":[{"code":"124","type":"MS-DRG"},{"code":"207","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Computed tomography guidance for placement of radiation therapy fields ","code_information":[{"code":"323","type":"RC"},{"code":"77014","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":230.22,"maximum":255.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":230.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":253.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":255.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":255.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":253.96,"methodology":"fee schedule"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"422","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bypass graft, with vein; femoral-popliteal ","code_information":[{"code":"35556","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, IgM ","code_information":[{"code":"0041U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28.31,"maximum":67.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67.12,"methodology":"fee schedule"}]}]},{"description":"Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) ","code_information":[{"code":"342","type":"RC"},{"code":"78014","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.20,"maximum":1239.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1116.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1231.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1239.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1239.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1231.30,"methodology":"fee schedule"}]}]},{"description":"Ultrasonic guidance for placement of radiation therapy fields ","code_information":[{"code":"409","type":"RC"},{"code":"G6001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":924.17,"maximum":1026.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":924.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1019.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1026.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1026.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1019.47,"methodology":"fee schedule"}]}]},{"description":"Ketogenic steroids, fractionation ","code_information":[{"code":"303","type":"RC"},{"code":"83582","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.45,"maximum":60.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":59.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":60.33,"methodology":"fee schedule"}]}]},{"description":"Culture, typing; identification by pulse field gel typing ","code_information":[{"code":"301","type":"RC"},{"code":"87152","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.73,"maximum":30.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":29.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":30.19,"methodology":"fee schedule"}]}]},{"description":"Amphotericin b liposome in ","code_information":[{"code":"00736","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":20.84,"maximum":21.05,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":20.84,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":21.05,"methodology":"fee schedule"}]}]},{"description":"Transection or avulsion of; phrenic nerve ","code_information":[{"code":"361","type":"RC"},{"code":"64746","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"114","type":"RC"},{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal ","code_information":[{"code":"361","type":"RC"},{"code":"44020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid ","code_information":[{"code":"62280","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC ","code_information":[{"code":"119","type":"RC"},{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Reduction of torsion of testis, surgical, with or without fixation of contralateral testis ","code_information":[{"code":"54600","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage ","code_information":[{"code":"361","type":"RC"},{"code":"67975","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Gastrectomy, partial, distal; with Roux-en-Y reconstruction ","code_information":[{"code":"43633","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; repair recurrent inguinal hernia ","code_information":[{"code":"49651","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is ","code_information":[{"code":"43259","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC ","code_information":[{"code":"098","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Drug metabolism or processing (mult conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes ","code_information":[{"code":"0347U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2197.87,"maximum":5210.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2197.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5135.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2442.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2442.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5210.75,"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, vertebral ar ","code_information":[{"code":"35005","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq ","code_information":[{"code":"481","type":"RC"},{"code":"C5275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary proced ","code_information":[{"code":"64462","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral ","code_information":[{"code":"0566T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Biopsy of testis, needle (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"54500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"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"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach ","code_information":[{"code":"369","type":"RC"},{"code":"63307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease (COVID-19)), includes titer(s), when performed ","code_information":[{"code":"0224U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":69.45,"maximum":164.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":69.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":162.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":77.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":77.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":164.66,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITH CC ","code_information":[{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":28649.25,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":34678.050,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":30888.380,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":34678.050,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":34678.050,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8006.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7718.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28649.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8576.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":24191.570,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":8458.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8576.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":23208.57,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":12650.33,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":8458.85,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":37377.540,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":41530.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":7850.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":11420.920,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":12983.500,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":10382.650,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":12983.500,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":23366.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8293.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":6634.40,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":14878.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":27508.830,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":14878.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":8624.71,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":49317.590,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":22115.040,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":13860.840,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7994.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":31822.820,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":8293.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":8293.00,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":8356.17,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":8541.78,"methodology":"fee schedule"}]}]},{"description":"Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; ","code_information":[{"code":"27740","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Ceruloplasmin ","code_information":[{"code":"82390","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.67,"maximum":41.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":41.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":41.89,"methodology":"fee schedule"}]}]},{"description":"Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal ","code_information":[{"code":"490","type":"RC"},{"code":"50325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closed treatment of metatarsal fracture; without manipulation, each ","code_information":[{"code":"28470","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions ","code_information":[{"code":"17111","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft ","code_information":[{"code":"25136","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater ","code_information":[{"code":"21554","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, mastoids; complete, minimum of 3 views per side ","code_information":[{"code":"323","type":"RC"},{"code":"70130","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":82.50,"maximum":91.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":82.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":91.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":91.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":91.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":91.00,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); qualitative, any number of analytes ","code_information":[{"code":"301","type":"RC"},{"code":"83015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.45,"maximum":81.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":80.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":81.67,"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Biopsy of breast; open, incisional ","code_information":[{"code":"19101","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, cervical spine; without contrast material ","code_information":[{"code":"320","type":"RC"},{"code":"72125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":683.93,"maximum":759.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":683.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":754.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":759.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":759.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":754.45,"methodology":"fee schedule"}]}]},{"description":"Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) ","code_information":[{"code":"21150","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":642.78,"maximum":1523.92,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":642.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1502.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":714.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":714.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1523.92,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion, esophagus, with primary repair; thoracic or abdominal approach ","code_information":[{"code":"361","type":"RC"},{"code":"43101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITH MCC ","code_information":[{"code":"080","type":"MS-DRG"},{"code":"138","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Dehydroepiandrosterone-sulfate (DHEA-S) ","code_information":[{"code":"306","type":"RC"},{"code":"82627","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.57,"maximum":86.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":85.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":86.70,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS  IPF","code_information":[{"code":"136","type":"RC"},{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1385.31,"maximum":1385.31,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1385.31,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of ","code_information":[{"code":"33951","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC ","code_information":[{"code":"017","type":"MS-DRG"},{"code":"110","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC ","code_information":[{"code":"115","type":"RC"},{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"112","type":"RC"},{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area) ","code_information":[{"code":"16030","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral ","code_information":[{"code":"324","type":"RC"},{"code":"77065","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":192.03,"maximum":213.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":192.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":211.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":213.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":213.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":211.83,"methodology":"fee schedule"}]}]},{"description":"Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff ","code_information":[{"code":"499","type":"RC"},{"code":"53446","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound as ","code_information":[{"code":"481","type":"RC"},{"code":"97602","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_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":"083","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm ","code_information":[{"code":"13131","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Cervical lymphadenectomy (complete) ","code_information":[{"code":"38720","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures) ","code_information":[{"code":"33548","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Therapeutic radiology simulation-aided field setting; complex ","code_information":[{"code":"409","type":"RC"},{"code":"77290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2299.43,"maximum":2554.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2299.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2536.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2554.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2554.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2536.53,"methodology":"fee schedule"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC ","code_information":[{"code":"073","type":"MS-DRG"},{"code":"110","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Drainage of retroperitoneal abscess, open ","code_information":[{"code":"49060","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Inj., triluron, 1 mg ","code_information":[{"code":"9338","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":8.22,"maximum":17.95,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":10.47,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":17.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":10.47,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":10.47,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":10.27,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":8.22,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":10.68,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10.32,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":10.27,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":10.27,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":10.68,"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":"64783","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar ","code_information":[{"code":"360","type":"RC"},{"code":"62292","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Temporomandibular joint arthrography, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"70332","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":421.63,"maximum":468.39,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":421.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":465.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":468.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":468.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":465.11,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction ","code_information":[{"code":"499","type":"RC"},{"code":"65265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Ligation or biopsy, temporal artery ","code_information":[{"code":"37609","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC ","code_information":[{"code":"067","type":"MS-DRG"},{"code":"145","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 5 cm or greater ","code_information":[{"code":"27616","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Open treatment of greater trochanteric fracture, includes internal fixation, when performed ","code_information":[{"code":"27248","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator, including imaging guidance, when performed ","code_information":[{"code":"0786T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chloride; other source ","code_information":[{"code":"306","type":"RC"},{"code":"82438","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.22,"maximum":19.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.50,"methodology":"fee schedule"}]}]},{"description":"Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tack) and all associated radiological supervision and interpretation ","code_information":[{"code":"34712","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Collagen based wound filler, dry form, sterile, per gram of collagen ","code_information":[{"code":"A6010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":34.62,"maximum":75.63,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":44.14,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":75.63,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":44.14,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":44.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":43.27,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":41.97,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":34.62,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":45.00,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":42.40,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":43.49,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":43.27,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":43.27,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":45.00,"methodology":"fee schedule"}]}]},{"description":"Plastic operation on penis to correct angulation ","code_information":[{"code":"499","type":"RC"},{"code":"54360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"092","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"761","type":"RC"},{"code":"G0448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC ","code_information":[{"code":"300","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6280.27,"maximum":6345.01,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":6280.27,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":6345.01,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation ","code_information":[{"code":"24565","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Inj adalimumab-fkjp, 1 mg ","code_information":[{"code":"826","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":10.55,"maximum":23.04,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":13.45,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":23.04,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":13.45,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":13.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":13.18,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":10.55,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":13.71,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.25,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":13.18,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":13.18,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":13.71,"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; full gene sequence ","code_information":[{"code":"302","type":"RC"},{"code":"81259","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":987.00,"maximum":2340.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":987.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2306.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1096.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1096.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2340.00,"methodology":"fee schedule"}]}]},{"description":"Amino acids, 6 or more amino acids, quantitative, each specimen ","code_information":[{"code":"300","type":"RC"},{"code":"82139","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.75,"maximum":65.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.79,"methodology":"fee schedule"}]}]},{"description":"Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct ","code_information":[{"code":"19110","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, quantification ","code_information":[{"code":"307","type":"RC"},{"code":"87562","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.47,"maximum":167.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":70.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":164.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":78.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":78.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":167.08,"methodology":"fee schedule"}]}]},{"description":"Addition to lower extremity orthosis, knee control, full kneecap ","code_information":[{"code":"L2795","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":102.11,"maximum":223.10,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":130.19,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":223.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":130.19,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":130.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":127.64,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":123.81,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":102.11,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":132.75,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":125.09,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":128.28,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":127.64,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":127.64,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":132.75,"methodology":"fee schedule"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC ","code_information":[{"code":"117","type":"RC"},{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"140","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Twist drill hole for subdural or ventricular puncture ","code_information":[{"code":"360","type":"RC"},{"code":"61105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Chemical peel, nonfacial; dermal ","code_information":[{"code":"15793","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"SEPTIC ARTHRITIS WITHOUT CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous ","code_information":[{"code":"10030","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Level 1 Nerve Procedures ","code_information":[{"code":"05431","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2062.96,"maximum":2084.23,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2062.96,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2084.23,"methodology":"fee schedule"}]}]},{"description":"Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and ","code_information":[{"code":"323","type":"RC"},{"code":"77300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":347.52,"maximum":386.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":347.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":383.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":386.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":386.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":383.35,"methodology":"fee schedule"}]}]},{"description":"Chromosome analysis; count 5 cells, 1 karyotype, with banding ","code_information":[{"code":"310","type":"RC"},{"code":"88261","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":434.84,"maximum":1030.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":434.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1016.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":483.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":483.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1030.93,"methodology":"fee schedule"}]}]},{"description":"Sphincterotomy, anal, division of sphincter (separate procedure) ","code_information":[{"code":"46080","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT ","code_information":[{"code":"014","type":"MS-DRG"},{"code":"111","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, hepatic, celiac, renal, or mesenteric artery ","code_information":[{"code":"35122","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Excision of major peripheral nerve neuroma, except sciatic, with implantation of nerve end into bone or muscle ","code_information":[{"code":"499","type":"RC"},{"code":"C7551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Urinalysis; 2 or 3 glass test ","code_information":[{"code":"303","type":"RC"},{"code":"81020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.73,"maximum":18.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":18.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18.33,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC ","code_information":[{"code":"577","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cystectomy, complete; (separate procedure) ","code_information":[{"code":"51570","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Repair of meningocele; less than 5 cm diameter ","code_information":[{"code":"360","type":"RC"},{"code":"63700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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"}],"standard_charges":[{"setting":"outpatient","minimum":4380.64,"maximum":23320.34,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":5585.32,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":9571.15,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":23320.34,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":23313.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":5585.32,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":5585.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":5475.80,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":4380.64,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":5694.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5503.18,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":5475.80,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":5475.80,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":5694.83,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands ","code_information":[{"code":"490","type":"RC"},{"code":"52214","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"SEPTIC ARTHRITIS WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants ","code_information":[{"code":"369","type":"RC"},{"code":"C9739","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE ","code_information":[{"code":"189","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Red cell antigen (H blood group) genotyping (FUT2), gene analysis, FUT2 (fycosyltransferase 2) exon 2 ","code_information":[{"code":"0186U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (eg, Stener lesion) ","code_information":[{"code":"29902","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Borrelia miyamotoi, amplified probe technique ","code_information":[{"code":"87478","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous ","code_information":[{"code":"0600T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Nasal smear for eosinophils ","code_information":[{"code":"37385","type":"CDM"},{"code":"89190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4.63,"maximum":24.64,"gross_charge":151.00,"discounted_cash":151.00,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":5.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":5.91,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":10.12,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24.64,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24.63,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":5.91,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":5.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":16.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":15.36,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":19.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":14.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":5.79,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5.81,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":4.63,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":6.02,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.82,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":5.79,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":5.79,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":5.31,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":6.02,"methodology":"fee schedule"}]}]},{"description":"URETHRAL STRICTURE ","code_information":[{"code":"169","type":"RC"},{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG ºany form»), utilizing maternal serum, algorithm reported as a risk score ","code_information":[{"code":"81510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.43,"maximum":236.53,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":56.65,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":97.08,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":236.53,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":236.46,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":56.65,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":56.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":162.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":184.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":147.38,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":184.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":141.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":55.54,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":55.71,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":44.43,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":57.76,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":56.28,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":55.82,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":55.54,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":55.54,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":57.76,"methodology":"fee schedule"}]}]},{"description":"Insulin tolerance panel; for ACTH insufficiency This panel must include the following: Cortisol (82533 x 5) Glucose (82947 x 5) ","code_information":[{"code":"307","type":"RC"},{"code":"80434","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":468.87,"maximum":1111.62,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":468.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1095.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":521.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":521.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1111.62,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, pelvis; 1 or 2 views ","code_information":[{"code":"329","type":"RC"},{"code":"72170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":145.05,"maximum":161.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":145.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":160.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":161.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":161.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":160.01,"methodology":"fee schedule"}]}]},{"description":"Phenytoin; free ","code_information":[{"code":"304","type":"RC"},{"code":"80186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.64,"maximum":53.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.66,"methodology":"fee schedule"}]}]},{"description":"Removal of lens material; pars plana approach, with or without vitrectomy ","code_information":[{"code":"361","type":"RC"},{"code":"66852","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH CC ","code_information":[{"code":"071","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bone marrow, smear interpretation ","code_information":[{"code":"85097","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1079.37,"maximum":2558.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1079.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2522.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2558.98,"methodology":"fee schedule"}]}]},{"description":"Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy) ","code_information":[{"code":"32442","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Revision mastoidectomy; resulting in complete mastoidectomy ","code_information":[{"code":"481","type":"RC"},{"code":"69601","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC ","code_information":[{"code":"492","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) ","code_information":[{"code":"323","type":"RC"},{"code":"77002","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":591.46,"maximum":657.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":591.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":652.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":657.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":657.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":652.45,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only ","code_information":[{"code":"361","type":"RC"},{"code":"43772","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":53343.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":33726.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53343.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":37473.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":37473.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53343.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Radiologic examination, chest; 3 views ","code_information":[{"code":"409","type":"RC"},{"code":"71047","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":151.94,"maximum":168.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":151.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":167.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":168.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":168.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":167.61,"methodology":"fee schedule"}]}]},{"description":"Ureterolithotomy; middle one-third of ureter ","code_information":[{"code":"369","type":"RC"},{"code":"50620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hematology (inherited thrombocytopenia), geonomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0276U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4027.88,"maximum":9549.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4027.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9412.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4475.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4475.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9549.38,"methodology":"fee schedule"}]}]},{"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, cervical spine; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"72125","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":447.80,"maximum":497.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":447.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":493.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":497.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":497.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":493.97,"methodology":"fee schedule"}]}]},{"description":"Dilation and catheterization of salivary duct, with or without injection ","code_information":[{"code":"369","type":"RC"},{"code":"42660","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"114","type":"RC"},{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bypass graft, with other than vein; axillary-femoral ","code_information":[{"code":"35621","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation ","code_information":[{"code":"20805","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"150","type":"RC"},{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Reduction forehead; contouring and setback of anterior frontal sinus wall ","code_information":[{"code":"21139","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Excision of thrombosed hemorrhoid, external ","code_information":[{"code":"46320","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed ","code_information":[{"code":"37226","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Unlisted cytopathology procedure ","code_information":[{"code":"312","type":"RC"},{"code":"88199","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.86,"maximum":194.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":194.06,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, skull; complete, minimum of 4 views ","code_information":[{"code":"329","type":"RC"},{"code":"70260","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":67.54,"maximum":75.03,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":67.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":74.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":75.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":75.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":74.50,"methodology":"fee schedule"}]}]},{"description":"BRONCHITIS AND ASTHMA WITH CC/MCC ","code_information":[{"code":"150","type":"RC"},{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy, muscle; superficial ","code_information":[{"code":"20200","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Repair choanal atresia; intranasal ","code_information":[{"code":"30540","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC ","code_information":[{"code":"169","type":"RC"},{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"115","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance ","code_information":[{"code":"361","type":"RC"},{"code":"45335","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; proctopexy (for prolapse) ","code_information":[{"code":"45400","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Brachytx, non-str,Yttrium- ","code_information":[{"code":"2616","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":13988.08,"maximum":30562.21,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":17834.80,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":30562.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":17834.80,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":17834.80,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":17485.10,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":13988.08,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":18184.50,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17572.53,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":17485.10,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":17485.10,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":18184.50,"methodology":"fee schedule"}]}]},{"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":"34847","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biopsy, soft tissue of neck or thorax ","code_information":[{"code":"21550","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Periodontal mucosal grafting ","code_information":[{"code":"41870","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Artificial insemination; intra-uterine ","code_information":[{"code":"58322","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography ","code_information":[{"code":"369","type":"RC"},{"code":"58340","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC ","code_information":[{"code":"057","type":"MS-DRG"},{"code":"118","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"303","type":"RC"},{"code":"81462","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1967.14,"maximum":4663.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1967.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4596.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2185.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2185.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4663.74,"methodology":"fee schedule"}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy or excision of lymph node(s); open, deep cervical node(s) ","code_information":[{"code":"38510","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"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":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3125.83,"maximum":7410.78,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3125.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7304.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3473.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3473.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":7410.78,"methodology":"fee schedule"}]}]},{"description":"Tubotubal anastomosis ","code_information":[{"code":"481","type":"RC"},{"code":"58750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral ","code_information":[{"code":"360","type":"RC"},{"code":"69706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Exemestane, 25 mg ","code_information":[{"code":"S0156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.78,"maximum":4.56,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":2.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4.56,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4.56,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed ","code_information":[{"code":"790","type":"RC"},{"code":"93451","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":14638.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8291.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14638.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9212.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9212.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14638.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC ","code_information":[{"code":"121","type":"RC"},{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":1160.06,"maximum":1183.26,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1183.26,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1160.06,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple ","code_information":[{"code":"43239","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"INBORN AND OTHER DISORDERS OF METABOLISM ","code_information":[{"code":"151","type":"RC"},{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC ","code_information":[{"code":"329","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HEART FAILURE AND SHOCK WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; ","code_information":[{"code":"31570","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Opioids and Opiate analogs; 5 or more ","code_information":[{"code":"80364","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.05,"maximum":47.03,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_percentage":41.30,"standard_charge_algorithm":"Reimbursement will be 41.3% of billable gross charges.","estimated_amount":309.640,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":47.60,"standard_charge_algorithm":"Reimbursement will be 47.6% of billable gross charges.","estimated_amount":356.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":41.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":47.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":37.63,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":47.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":36.05,"methodology":"fee schedule"}]}]},{"description":"Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study ","code_information":[{"code":"402","type":"RC"},{"code":"76828","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":115.19,"maximum":127.96,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":115.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":127.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":127.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":127.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":127.06,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC  IPF","code_information":[{"code":"146","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1113.66,"maximum":1113.66,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1113.66,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length ","code_information":[{"code":"64891","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) ","code_information":[{"code":"27120","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12033.90,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) ","code_information":[{"code":"21235","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ACUTE LEUKEMIA WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma ","code_information":[{"code":"0055U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5329.80,"maximum":12636.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5329.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":12454.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12636.00,"methodology":"fee schedule"}]}]},{"description":"Replacement or irrigation, subarachnoid/subdural catheter ","code_information":[{"code":"361","type":"RC"},{"code":"62194","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"70480","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":305.06,"maximum":338.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":305.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":336.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":336.51,"methodology":"fee schedule"}]}]},{"description":"Toxin or antitoxin assay, tissue culture (eg, Clostridium difficile toxin) ","code_information":[{"code":"300","type":"RC"},{"code":"87230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.47,"maximum":76.99,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":75.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":76.99,"methodology":"fee schedule"}]}]},{"description":"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC ","code_information":[{"code":"327","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique ","code_information":[{"code":"305","type":"RC"},{"code":"87537","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.06,"maximum":85.49,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":84.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":85.49,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC ","code_information":[{"code":"356","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) ","code_information":[{"code":"25066","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"207","type":"RC"},{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT C ","code_information":[{"code":"130","type":"RC"},{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  IPF","code_information":[{"code":"154","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1033.33,"maximum":1054.00,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1054.00,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1033.33,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"FRACTURES OF FEMUR WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"127","type":"RC"},{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Protein c concentrate ","code_information":[{"code":"01139","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":14.59,"maximum":14.74,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":14.59,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14.74,"methodology":"fee schedule"}]}]},{"description":"Arterial puncture, withdrawal of blood for diagnosis ","code_information":[{"code":"36600","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC ","code_information":[{"code":"350","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence r ","code_information":[{"code":"309","type":"RC"},{"code":"81520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4129.30,"maximum":9789.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4129.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9649.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4588.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4588.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9789.82,"methodology":"fee schedule"}]}]},{"description":"Antibody; Campylobacter ","code_information":[{"code":"303","type":"RC"},{"code":"86625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.58,"maximum":51.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.17,"methodology":"fee schedule"}]}]},{"description":"Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); cutdown ","code_information":[{"code":"36625","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Thoracic fascial plane block, bilateral; by continuous infusion(s), including imaging guidance, when performed ","code_information":[{"code":"360","type":"RC"},{"code":"64469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Transposition, ovary(s) ","code_information":[{"code":"369","type":"RC"},{"code":"58825","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITH MCC ","code_information":[{"code":"138","type":"RC"},{"code":"725","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DIGESTIVE MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"202","type":"RC"},{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Angiography, adrenal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75733","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":590.23,"maximum":655.68,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":590.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":651.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":655.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":655.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":651.09,"methodology":"fee schedule"}]}]},{"description":"Ligation, major artery (eg, post-traumatic, rupture); extremity ","code_information":[{"code":"369","type":"RC"},{"code":"37618","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"OSTEOMYELITIS WITHOUT CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Synovectomy, tendon sheath, foot; flexor ","code_information":[{"code":"28086","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"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":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment ","code_information":[{"code":"L2114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":615.37,"maximum":1344.50,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":784.59,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1344.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":784.59,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":784.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":769.21,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":746.13,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":615.37,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":799.98,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":753.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":773.06,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":769.21,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":769.21,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":799.98,"methodology":"fee schedule"}]}]},{"description":"Pulmonary ventilation imaging (eg, aerosol or gas) ","code_information":[{"code":"340","type":"RC"},{"code":"78579","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":112.87,"maximum":125.39,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":112.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":124.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":125.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":125.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":124.51,"methodology":"fee schedule"}]}]},{"description":"Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) ","code_information":[{"code":"0089U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.20,"maximum":2964.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2921.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2964.00,"methodology":"fee schedule"}]}]},{"description":"Factor viii pegylated reco ","code_information":[{"code":"01844","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2.03,"maximum":2.06,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2.03,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2.06,"methodology":"fee schedule"}]}]},{"description":"CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"304","type":"RC"},{"code":"81184","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) ","code_information":[{"code":"21348","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Mechanical fragility, RBC, shear stress and spectral analysis profiling ","code_information":[{"code":"0123U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":588.30,"maximum":1394.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":588.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1374.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":653.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":653.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1394.76,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"212","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tenolysis, triceps ","code_information":[{"code":"24332","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"316","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3427.76,"maximum":3463.10,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3427.76,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3463.10,"methodology":"fee schedule"}]}]},{"description":"Opponensplasty; other methods ","code_information":[{"code":"26496","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Removal of blood clot, anterior segment of eye ","code_information":[{"code":"65930","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"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":"329","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":219.84,"maximum":244.22,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":219.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":242.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":244.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":244.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":242.51,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC ","code_information":[{"code":"209","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach ","code_information":[{"code":"46744","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with catheter placement(s) ","code_information":[{"code":"C7520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21416.00,"maximum":25567.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21416.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":25567.00,"methodology":"case rate"}]}]},{"description":"Arthrotomy, hip, with drainage (eg, infection) ","code_information":[{"code":"27030","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Unlisted cytogenetic study ","code_information":[{"code":"319","type":"RC"},{"code":"88299","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.86,"maximum":194.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":194.06,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thymectomy, partial or total; transcervical approach (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"60520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC ","code_information":[{"code":"418","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance ","code_information":[{"code":"37187","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"695","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"400","type":"RC"},{"code":"77080","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":47.13,"maximum":52.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":47.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":52.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":52.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.99,"methodology":"fee schedule"}]}]},{"description":"Histamine ","code_information":[{"code":"302","type":"RC"},{"code":"83088","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":48.58,"maximum":115.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":48.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":113.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":115.17,"methodology":"fee schedule"}]}]},{"description":"Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed ","code_information":[{"code":"342","type":"RC"},{"code":"78598","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":1210.01,"maximum":1344.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1210.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1334.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1344.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1344.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1334.77,"methodology":"fee schedule"}]}]},{"description":"New Technology - Level 18 ","code_information":[{"code":"01518","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1743.63,"maximum":1761.61,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1743.63,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1761.61,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance ","code_information":[{"code":"37187","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Borrelia miyamotoi, amplified probe technique ","code_information":[{"code":"307","type":"RC"},{"code":"87478","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation ","code_information":[{"code":"0565T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Oncology (breast cancer), DNA, PIK3CA gene analysis of 11 gene variants utilizing plasma, reported as PIK3CA gene mutation status ","code_information":[{"code":"0177U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":452.10,"maximum":1071.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":452.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1056.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1071.84,"methodology":"fee schedule"}]}]},{"description":"Cranioplasty for skull defect with reparative brain surgery ","code_information":[{"code":"369","type":"RC"},{"code":"62145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia ","code_information":[{"code":"26770","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock ","code_information":[{"code":"15835","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH MCC ","code_information":[{"code":"118","type":"RC"},{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device ","code_information":[{"code":"0449T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less ","code_information":[{"code":"11300","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"77021","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":1814.37,"maximum":2015.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1814.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2001.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2015.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2015.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2001.45,"methodology":"fee schedule"}]}]},{"description":"IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B-cell), variable region somatic mutation analysis ","code_information":[{"code":"302","type":"RC"},{"code":"81263","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":484.49,"maximum":1148.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":484.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1132.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":538.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":538.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1148.63,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  IPF","code_information":[{"code":"124","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1033.33,"maximum":1054.00,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1054.00,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1033.33,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Repair of entropion; excision tarsal wedge ","code_information":[{"code":"67923","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"INBORN AND OTHER DISORDERS OF METABOLISM ","code_information":[{"code":"153","type":"RC"},{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; cryptosporidium ","code_information":[{"code":"87272","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.58,"maximum":51.04,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":12.22,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":20.94,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":51.04,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":51.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":12.22,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":12.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":38.88,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":44.18,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":35.35,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":44.18,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":33.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":11.98,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12.02,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9.58,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12.14,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.04,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11.98,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":11.98,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":10.98,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12.46,"methodology":"fee schedule"}]}]},{"description":"Debridement of nail(s) by any method(s); 1 to 5 ","code_information":[{"code":"11720","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Contact lens, scleral, gas impermeable, per lens (for contact lens modification, see 92325) ","code_information":[{"code":"V2530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":285.54,"maximum":623.88,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":364.07,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":623.88,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":364.07,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":364.07,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":356.93,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":346.22,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":285.54,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":371.21,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":349.79,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":358.71,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":356.93,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":356.93,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":371.21,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC ","code_information":[{"code":"118","type":"RC"},{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) ","code_information":[{"code":"499","type":"RC"},{"code":"57105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Radiologic examination, hips, bilateral, with pelvis when performed; 2 views ","code_information":[{"code":"321","type":"RC"},{"code":"73521","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":54.02,"maximum":60.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":54.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":59.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":60.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":60.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":59.59,"methodology":"fee schedule"}]}]},{"description":"Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis, utilizing formalin-fixed paraffin-embedded tissue ","code_information":[{"code":"0111U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1122.37,"maximum":2660.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1122.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2622.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1247.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1247.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2660.93,"methodology":"fee schedule"}]}]},{"description":"KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) ","code_information":[{"code":"81275","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":317.90,"maximum":753.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":742.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":753.67,"methodology":"fee schedule"}]}]},{"description":"Red cell volume determination (separate procedure); multiple samplings ","code_information":[{"code":"342","type":"RC"},{"code":"78121","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":74.27,"maximum":82.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":74.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":81.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":82.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":82.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":81.93,"methodology":"fee schedule"}]}]},{"description":"Open treatment of depressed malar fracture, including zygomatic arch and malar tripod ","code_information":[{"code":"21360","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separat ","code_information":[{"code":"15774","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH CC ","code_information":[{"code":"164","type":"RC"},{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision (eg, augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed ","code_information":[{"code":"0790T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RENAL FAILURE WITH MCC ","code_information":[{"code":"114","type":"RC"},{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"81184","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"REPOSITIONING OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; STIMULATION LEAD ONLY ","code_information":[{"code":"0432T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection, sodium thiosulfate (hope), 100 mg ","code_information":[{"code":"J0209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.87,"maximum":2.20,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2.20,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":0.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.09,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.87,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.09,"methodology":"fee schedule"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Mucoprotein, blood (seromucoid) (medical necessity procedure) ","code_information":[{"code":"307","type":"RC"},{"code":"P2038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.14,"maximum":19.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.30,"methodology":"fee schedule"}]}]},{"description":"Citrate ","code_information":[{"code":"82507","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":45.73,"maximum":108.42,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":45.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":106.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":50.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":50.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":108.42,"methodology":"fee schedule"}]}]},{"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":"34846","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination; toe(s), minimum of 2 views ","code_information":[{"code":"400","type":"RC"},{"code":"73660","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":150.60,"maximum":167.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":150.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":166.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":167.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":167.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":166.13,"methodology":"fee schedule"}]}]},{"description":"Inj, human-lans, per i.u ","code_information":[{"code":"702","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.24,"maximum":2.70,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1.58,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1.58,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1.58,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1.55,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1.24,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1.61,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1.55,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1.55,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1.55,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1.61,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HYPERTENSION WITHOUT MCC ","code_information":[{"code":"110","type":"RC"},{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Deoxyribonucleic acid (DNA) antibody; single stranded ","code_information":[{"code":"309","type":"RC"},{"code":"86226","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.92,"maximum":47.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47.23,"methodology":"fee schedule"}]}]},{"description":"Dilation of esophagus, over guide wire ","code_information":[{"code":"43453","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"144","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":855.13,"maximum":872.23,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":872.23,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":855.13,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"MRI and MRA with Contrast ","code_information":[{"code":"08008","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":903.07,"maximum":912.38,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":903.07,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":912.38,"methodology":"fee schedule"}]}]},{"description":"Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass ","code_information":[{"code":"32854","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed) ","code_information":[{"code":"499","type":"RC"},{"code":"64489","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITHOUT CC/MCC ","code_information":[{"code":"158","type":"RC"},{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"56606","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) ","code_information":[{"code":"402","type":"RC"},{"code":"76705","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":139.76,"maximum":155.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":139.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":154.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":155.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":155.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":154.17,"methodology":"fee schedule"}]}]},{"description":"HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC ","code_information":[{"code":"369","type":"RC"},{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Lenticular lens, per lens, single ","code_information":[{"code":"V2121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":81.94,"maximum":179.02,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":104.47,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":179.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":104.47,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":104.47,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":102.42,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":99.35,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":81.94,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":106.52,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":100.37,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":102.93,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":102.42,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":102.42,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":106.52,"methodology":"fee schedule"}]}]},{"description":"Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing ","code_information":[{"code":"301","type":"RC"},{"code":"81413","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":962.16,"maximum":2281.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":962.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2248.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2281.11,"methodology":"fee schedule"}]}]},{"description":"Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation ","code_information":[{"code":"481","type":"RC"},{"code":"67105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) ","code_information":[{"code":"37784","type":"CDM"},{"code":"84479","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.18,"maximum":27.58,"gross_charge":280.50,"discounted_cash":280.50,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":5.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":6.60,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":11.31,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":27.58,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":27.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":6.60,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":6.60,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":20.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":23.82,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":19.05,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":23.82,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":18.26,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":6.47,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":6.49,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":5.18,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":6.73,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":6.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6.50,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":6.47,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":6.47,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":5.94,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":6.73,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family ","code_information":[{"code":"36217","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC ","code_information":[{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":44594.93,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":62660.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":55812.650,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":62660.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":62660.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":12667.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12014.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44594.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13350.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":43712.090,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":13166.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13350.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36126.06,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":19691.29,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":13166.90,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":67537.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":75042.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":12421.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":20636.610,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":23460.070,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":18760.550,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":23460.070,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":42220.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":12908.73,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":10326.98,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":26883.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":49706.090,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":26883.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":13425.08,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":89112.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":39959.980,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":25045.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12444.02,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":57501.100,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":12908.73,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":12908.73,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13220.68,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":13295.99,"methodology":"fee schedule"}]}]},{"description":"Autoimmune (Rheumatoid arthritis),next-gen sequencing (NGS),gene expression testing of 19 genes,whole blood,with analysis of anticyclic citrullinated peptides (CCP) levels,combined with sex,patient gl ","code_information":[{"code":"0456U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1932.30,"maximum":2520.84,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":2218.36,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":2520.84,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":2016.74,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":2520.84,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":1932.30,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with dilation, subsequent ","code_information":[{"code":"31529","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal ","code_information":[{"code":"20962","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"RECTAL RESECTION WITH CC ","code_information":[{"code":"333","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ALLERGIC REACTIONS WITHOUT MCC ","code_information":[{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":26105.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":27261.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":24282.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":27261.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":27261.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":4788.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4802.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17823.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5335.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":19017.690,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":5262.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5335.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14438.72,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":7870.14,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":5262.50,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":29383.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":32648.400,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":4695.55,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":8978.310,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":10206.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":8162.100,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":10206.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":18368.810,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":5159.31,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":4127.45,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":11696.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":21625.480,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":11696.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":5365.68,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":38769.970,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":17385.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":10896.400,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4973.58,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":25016.840,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":5159.31,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":5159.31,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":4997.74,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":5314.09,"methodology":"fee schedule"}]}]},{"description":"Respiratory motion management simulation (List separately in addition to code for primary procedure) ","code_information":[{"code":"324","type":"RC"},{"code":"77293","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2096.14,"maximum":2328.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2096.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2312.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2328.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2328.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2312.28,"methodology":"fee schedule"}]}]},{"description":"Transrectal drainage of pelvic abscess ","code_information":[{"code":"45000","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) ","code_information":[{"code":"52342","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery ","code_information":[{"code":"31241","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE ","code_information":[{"code":"143","type":"RC"},{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; with autograft requiring separate incision ","code_information":[{"code":"27067","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) ","code_information":[{"code":"27720","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"ANGINA PECTORIS ","code_information":[{"code":"167","type":"RC"},{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"92921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18354.00,"maximum":32157.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18354.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":32157.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":32157.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach) ","code_information":[{"code":"33202","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair, acquired or traumatic arteriovenous fistula; head and neck ","code_information":[{"code":"35188","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Lightweight portable motorized/power wheelchair ","code_information":[{"code":"K0012","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":363.18,"maximum":793.49,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":463.05,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":793.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":463.05,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":463.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":453.97,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":440.35,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":363.18,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":472.13,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":444.89,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":456.24,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":453.97,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":453.97,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":472.13,"methodology":"fee schedule"}]}]},{"description":"New Technology - Level 34 ","code_information":[{"code":"01571","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":8716.05,"maximum":8805.91,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":8716.05,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":8805.91,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"814","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC ","code_information":[{"code":"144","type":"RC"},{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"151","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC ","code_information":[{"code":"210","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical ","code_information":[{"code":"22210","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"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":"303","type":"RC"},{"code":"81110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":201.05,"maximum":476.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":201.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":469.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":476.66,"methodology":"fee schedule"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH CC ","code_information":[{"code":"149","type":"RC"},{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Lamotrigine ","code_information":[{"code":"301","type":"RC"},{"code":"80175","type":"CPT"},{"code":"82322","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":21.80,"maximum":51.67,"gross_charge":570.00,"discounted_cash":570.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.67,"methodology":"fee schedule"}]}]},{"description":"Radiologic small intestine follow-through study, including multiple serial images (List separately in addition to code for primary procedure for upper GI radiologic examination) ","code_information":[{"code":"320","type":"RC"},{"code":"74248","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":420.04,"maximum":466.62,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":420.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":463.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":466.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":466.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":463.35,"methodology":"fee schedule"}]}]},{"description":"EPISTAXIS WITHOUT MCC ","code_information":[{"code":"113","type":"RC"},{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS ","code_information":[{"code":"169","type":"RC"},{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sphere, single vision, plano to plus or minus 4.00, per lens ","code_information":[{"code":"V2100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":37.62,"maximum":82.19,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":47.96,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":82.19,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":47.96,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":47.96,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":47.02,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":45.61,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":37.62,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":48.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":46.08,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":47.26,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":47.02,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":47.02,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":48.90,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC ","code_information":[{"code":"144","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"307","type":"RC"},{"code":"81180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"Exposure of prostate, any approach, for insertion of radioactive substance; ","code_information":[{"code":"55860","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Repair of anomalous coronary artery from pulmonary artery origin; with construction of intrapulmonary artery tunnel (Takeuchi procedure) ","code_information":[{"code":"33505","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"119","type":"RC"},{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Mastectomy for gynecomastia ","code_information":[{"code":"19300","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC ","code_information":[{"code":"241","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; ","code_information":[{"code":"31540","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately ","code_information":[{"code":"22868","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC ","code_information":[{"code":"154","type":"RC"},{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MAJOR CHEST TRAUMA WITH MCC ","code_information":[{"code":"183","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":40924.83,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":58512.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":52118.280,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":58512.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":58512.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":11446.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11025.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":40924.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12251.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":40818.690,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":12083.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12251.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":33152.93,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":18070.72,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":12083.29,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":63067.500,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":70075.000,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":11224.07,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":19270.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":21907.200,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":17518.750,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":21907.200,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":39425.950,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":11846.36,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9477.09,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":25104.370,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":46415.930,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":25104.370,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12320.21,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":83214.060,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":37314.940,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":23387.530,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11419.89,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":53694.970,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11846.36,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":11846.36,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11946.41,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12201.75,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia ","code_information":[{"code":"26670","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each ","code_information":[{"code":"A6599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.33,"maximum":2.90,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1.69,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2.90,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1.69,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1.69,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1.66,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1.61,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1.33,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1.73,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1.63,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1.67,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1.66,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1.66,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1.73,"methodology":"fee schedule"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; common femoral ","code_information":[{"code":"35371","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Vulvectomy, radical, partial; ","code_information":[{"code":"481","type":"RC"},{"code":"56630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":12033.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, and lower mediastinal esophagus, with separate laparoscopic proximal gastrectomy, with laparoscopic pyloric dr ","code_information":[{"code":"361","type":"RC"},{"code":"43288","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Carboxyhemoglobin; qualitative ","code_information":[{"code":"305","type":"RC"},{"code":"82376","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.15,"maximum":54.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":54.87,"methodology":"fee schedule"}]}]},{"description":"Cerclage of cervix, during pregnancy; abdominal ","code_information":[{"code":"360","type":"RC"},{"code":"59325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"URETHRAL PROCEDURES WITH CC/MCC ","code_information":[{"code":"360","type":"RC"},{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transection or avulsion of other spinal nerve, extradural ","code_information":[{"code":"490","type":"RC"},{"code":"64772","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Open treatment of radial shaft fracture, includes internal fixation, when performed ","code_information":[{"code":"25515","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC ","code_information":[{"code":"026","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Virus isolation; including identification by non-immunologic method, other than by cytopathic effect (eg, virus specific enzymatic activity) ","code_information":[{"code":"305","type":"RC"},{"code":"87255","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.70,"maximum":132.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":130.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":61.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":61.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":132.05,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease ","code_information":[{"code":"43257","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Prostatotomy, external drainage of prostatic abscess, any approach; simple ","code_information":[{"code":"55720","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments ","code_information":[{"code":"499","type":"RC"},{"code":"63103","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75885","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":325.10,"maximum":361.16,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":325.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":358.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":361.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":361.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":358.63,"methodology":"fee schedule"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy ","code_information":[{"code":"15830","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; double-contrast (eg, high density barium and air) study, including glucagon, when administe ","code_information":[{"code":"409","type":"RC"},{"code":"74280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1116.77,"maximum":1240.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1116.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1231.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1240.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1240.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1231.92,"methodology":"fee schedule"}]}]},{"description":"SKIN ULCERS WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"New Technology  - Level 1E ","code_information":[{"code":"01495","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":48.07,"maximum":48.56,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":48.07,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":48.56,"methodology":"fee schedule"}]}]},{"description":"Activated Protein C (APC) resistance assay ","code_information":[{"code":"309","type":"RC"},{"code":"85307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.20,"maximum":59.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":58.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":59.75,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE ","code_information":[{"code":"114","type":"RC"},{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Urethrorrhaphy, suture of urethral wound or injury; penile ","code_information":[{"code":"53505","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Injection, etidronate disodium, per 300 mg ","code_information":[{"code":"J1436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":78.95,"maximum":98.69,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":86.86,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":98.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":78.95,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":98.69,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin; plasma ","code_information":[{"code":"304","type":"RC"},{"code":"83051","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.02,"maximum":28.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.51,"methodology":"fee schedule"}]}]},{"description":"HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (eg, citalopram metabolism) gene analysis, common variants (ie, HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-75 ","code_information":[{"code":"0033U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":575.12,"maximum":1363.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":575.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1343.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":639.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":639.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1363.52,"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":"304","type":"RC"},{"code":"G0482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":326.93,"maximum":775.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":326.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":763.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":363.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":363.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":775.09,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"214","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Replacement or irrigation, subarachnoid/subdural catheter ","code_information":[{"code":"360","type":"RC"},{"code":"62194","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Removal of ventricular assist device; extracorporeal, biventricular ","code_information":[{"code":"33978","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC ","code_information":[{"code":"068","type":"MS-DRG"},{"code":"212","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transcutaneous tibial nerve stimulator ","code_information":[{"code":"E0736","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":41.09,"maximum":89.77,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":52.39,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":89.77,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":52.39,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":52.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":51.36,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":49.82,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":41.09,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":53.41,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":50.33,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":51.62,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":51.36,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":51.36,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":53.41,"methodology":"fee schedule"}]}]},{"description":"Exploration, retroperitoneal area with or without biopsy(s) (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"49010","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC ","code_information":[{"code":"490","type":"RC"},{"code":"928","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure) ","code_information":[{"code":"44213","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); for exploration, with or without biopsy ","code_information":[{"code":"499","type":"RC"},{"code":"67450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Fetal umbilical cord occlusion, including ultrasound guidance ","code_information":[{"code":"59072","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH MCC ","code_information":[{"code":"031","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC ","code_information":[{"code":"490","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of foreign body, external eye; conjunctival superficial ","code_information":[{"code":"481","type":"RC"},{"code":"65205","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Ureteroenterostomy, direct anastomosis of ureter to intestine ","code_information":[{"code":"499","type":"RC"},{"code":"50800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Colonoscopy, flexible; with endoscopic mucosal resection ","code_information":[{"code":"45390","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay ºeg, dipsticks, cups, ca ","code_information":[{"code":"304","type":"RC"},{"code":"80305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.73,"maximum":49.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":48.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":49.14,"methodology":"fee schedule"}]}]},{"description":"Osteoplasty, femur; shortening (excluding 64876) ","code_information":[{"code":"27465","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; mesenteric, celiac, or renal ","code_information":[{"code":"35341","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"101","type":"RC"},{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT ","code_information":[{"code":"124","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cholecystectomy; with cholangiography ","code_information":[{"code":"47605","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or b ","code_information":[{"code":"22515","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8240.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8240.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17303.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9155.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9155.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17303.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Amino acids; single, qualitative, each specimen ","code_information":[{"code":"301","type":"RC"},{"code":"82127","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.33,"maximum":55.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":55.30,"methodology":"fee schedule"}]}]},{"description":"Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); ","code_information":[{"code":"19301","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination; calcaneus, minimum of 2 views ","code_information":[{"code":"409","type":"RC"},{"code":"73650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":146.85,"maximum":163.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":146.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":161.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":163.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":163.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":161.99,"methodology":"fee schedule"}]}]},{"description":"Albumin (human), 5%, 250 m ","code_information":[{"code":"963","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":42.46,"maximum":92.77,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":54.14,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":92.77,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":54.14,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":54.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":53.08,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":42.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":55.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":53.34,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":53.08,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":53.08,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":55.20,"methodology":"fee schedule"}]}]},{"description":"Excision, local; malignant tumor of stomach ","code_information":[{"code":"43611","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Microsomal antibodies (eg, thyroid or liver-kidney), each ","code_information":[{"code":"301","type":"RC"},{"code":"86376","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.93,"maximum":56.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.75,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of shoulder area; superficial ","code_information":[{"code":"23065","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary procedure) ","code_information":[{"code":"33768","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) ","code_information":[{"code":"26862","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session ","code_information":[{"code":"41530","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC ","code_information":[{"code":"083","type":"MS-DRG"},{"code":"208","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITH CC ","code_information":[{"code":"336","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12517.66,"maximum":12646.70,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12517.66,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12646.70,"methodology":"fee schedule"}]}]},{"description":"Fibrinogen; antigen ","code_information":[{"code":"303","type":"RC"},{"code":"85385","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.79,"maximum":56.39,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.39,"methodology":"fee schedule"}]}]},{"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":"50432","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism ","code_information":[{"code":"87299","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":26.48,"maximum":62.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.79,"methodology":"fee schedule"}]}]},{"description":"Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), initial ","code_information":[{"code":"32505","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"PNEUMOTHORAX WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"24076","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"ABORTION WITHOUT D&C ","code_information":[{"code":"210","type":"RC"},{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Splenoportography, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75810","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":239.83,"maximum":266.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":239.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":264.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":266.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":266.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":264.56,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"158","type":"RC"},{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"T cells; absolute CD4 and CD8 count, including ratio ","code_information":[{"code":"309","type":"RC"},{"code":"86360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":77.28,"maximum":183.22,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":77.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":180.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":85.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":85.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":183.22,"methodology":"fee schedule"}]}]},{"description":"New Technology - Level 49 ","code_information":[{"code":"1901","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":93663.04,"maximum":204642.03,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":119420.38,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":204642.03,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":119420.38,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":119420.38,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":117078.80,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":93663.04,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":121761.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":117664.19,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":117078.80,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":117078.80,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":121761.95,"methodology":"fee schedule"}]}]},{"description":"Level 2 Neurostimulator an ","code_information":[{"code":"5462","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":5718.12,"maximum":12493.38,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":7290.61,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":12493.38,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":7290.61,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":7290.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":7147.65,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":5718.12,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":7433.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7183.39,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":7147.65,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":7147.65,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":7433.56,"methodology":"fee schedule"}]}]},{"description":"REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; REDUCIBLE ","code_information":[{"code":"490","type":"RC"},{"code":"49560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Biopsy, vestibule of mouth ","code_information":[{"code":"369","type":"RC"},{"code":"40808","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"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":"87390","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.58,"maximum":93.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":39.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":92.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":43.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":43.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":93.83,"methodology":"fee schedule"}]}]},{"description":"Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only ","code_information":[{"code":"30460","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm ","code_information":[{"code":"15836","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) ","code_information":[{"code":"45120","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Subcutaneous injection of filling material (eg, collagen); 1 cc or less ","code_information":[{"code":"11950","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Destruction of vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"499","type":"RC"},{"code":"57065","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Adrenal imaging, cortex and/or medulla ","code_information":[{"code":"349","type":"RC"},{"code":"78075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2074.09,"maximum":2304.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2074.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2287.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2304.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2304.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2287.96,"methodology":"fee schedule"}]}]},{"description":"Repair of blepharoptosis; (tarso) levator resection or advancement, external approach ","code_information":[{"code":"67904","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) ","code_information":[{"code":"22846","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, ","code_information":[{"code":"303","type":"RC"},{"code":"81471","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1503.53,"maximum":3564.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1503.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3513.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1670.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1670.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3564.60,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC* ","code_information":[{"code":"191","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5299.96,"maximum":5354.60,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5299.96,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5354.60,"methodology":"fee schedule"}]}]},{"description":"Lymphocyte immune globulin ","code_information":[{"code":"00890","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":4981.04,"maximum":5032.39,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":4981.04,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5032.39,"methodology":"fee schedule"}]}]},{"description":"SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE PREGNANCY REQUIRING TOTAL HYSTERECTOMY ","code_information":[{"code":"490","type":"RC"},{"code":"59135","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC ","code_information":[{"code":"212","type":"RC"},{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft) ","code_information":[{"code":"31546","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos ","code_information":[{"code":"89251","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Ileoscopy, through stoma; with biopsy, single or multiple ","code_information":[{"code":"360","type":"RC"},{"code":"44382","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Complex uroflowmetry (eg, calibrated electronic equipment) ","code_information":[{"code":"51741","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, osseous survey; limited (eg, for metastases) ","code_information":[{"code":"321","type":"RC"},{"code":"77074","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":234.23,"maximum":260.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":234.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":258.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":260.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":260.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":258.38,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of fracture of orbit, except blowout; with manipulation ","code_information":[{"code":"21401","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"095","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Antibody; respiratory syncytial virus ","code_information":[{"code":"303","type":"RC"},{"code":"86756","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.14,"maximum":61.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.97,"methodology":"fee schedule"}]}]},{"description":"Thoracic fascial plane block, unilateral; by continuous infusion(s), including imaging guidance, when performed ","code_information":[{"code":"64467","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":1221.03,"maximum":2894.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1221.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2853.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1356.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1356.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2894.85,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"146","type":"RC"},{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Trimming of nondystrophic nails, any number ","code_information":[{"code":"11719","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Phalangectomy, toe, each toe ","code_information":[{"code":"28150","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) ","code_information":[{"code":"58700","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Removal of ventricular assist device; extracorporeal, single ventricle ","code_information":[{"code":"33977","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Complete aa, per square centimeter ","code_information":[{"code":"Q4303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3295.48,"maximum":9153.10,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9153.10,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9153.10,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4150.98,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4716.48,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3773.18,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4716.48,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3295.48,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3329.45,"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":588.30,"maximum":1394.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":588.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1374.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":653.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":653.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1394.76,"methodology":"fee schedule"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; with cyclectomy ","code_information":[{"code":"369","type":"RC"},{"code":"66605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Computed tomography, lower extremity; with contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"73701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":876.32,"maximum":973.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":876.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":966.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":973.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":973.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":966.68,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"0799T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators ","code_information":[{"code":"409","type":"RC"},{"code":"77610","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":3171.79,"maximum":3523.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3171.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3498.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3523.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3523.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3498.84,"methodology":"fee schedule"}]}]},{"description":"Cold agglutinin; titer ","code_information":[{"code":"302","type":"RC"},{"code":"37203","type":"CDM"},{"code":"86157","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.26,"maximum":31.43,"gross_charge":202.00,"discounted_cash":202.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":30.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":31.43,"methodology":"fee schedule"}]}]},{"description":"Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated ","code_information":[{"code":"490","type":"RC"},{"code":"49501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Gastrectomy, partial, distal; with gastrojejunostomy ","code_information":[{"code":"369","type":"RC"},{"code":"43632","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Infectious disease (bacteria, fungi, parasites, and DNA viruses), DNA, PCR and next-generation sequencing, plasma, detection of >1,000 potential microbial organisms for significant positive pathogens ","code_information":[{"code":"0152U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3497.60,"maximum":8292.18,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3497.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8173.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3886.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3886.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8292.18,"methodology":"fee schedule"}]}]},{"description":"Valproic acid (dipropylacetic acid); total ","code_information":[{"code":"304","type":"RC"},{"code":"80164","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.27,"maximum":52.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.81,"methodology":"fee schedule"}]}]},{"description":"Repair, flexor tendon, leg; primary, without graft, each tendon ","code_information":[{"code":"27658","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Computed tomography, thorax, diagnostic; with contrast material(s) ","code_information":[{"code":"322","type":"RC"},{"code":"71260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":878.07,"maximum":975.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":878.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":968.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":975.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":975.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":968.61,"methodology":"fee schedule"}]}]},{"description":"Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiolo ","code_information":[{"code":"37218","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; REDUCIBLE ","code_information":[{"code":"49560","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Discography, lumbar, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"72295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":573.16,"maximum":636.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":573.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":632.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":636.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":636.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":632.26,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"146","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"RESPIRATORY NEOPLASMS WITH CC ","code_information":[{"code":"181","type":"MS-DRG"},{"code":"207","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contras ","code_information":[{"code":"481","type":"RC"},{"code":"C7515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation ","code_information":[{"code":"61698","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Level 3 Therapeutic Radiat ","code_information":[{"code":"5613","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1192.14,"maximum":2604.67,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1519.98,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2604.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1519.98,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1519.98,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1490.17,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1192.14,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1549.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1497.62,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1490.17,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1490.17,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1549.78,"methodology":"fee schedule"}]}]},{"description":"Estradiol; free, direct measurement (eg, equilibrium dialysis) ","code_information":[{"code":"306","type":"RC"},{"code":"82681","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":45.96,"maximum":108.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":45.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":107.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":51.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":51.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":108.97,"methodology":"fee schedule"}]}]},{"description":"Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach ","code_information":[{"code":"369","type":"RC"},{"code":"50525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21 ","code_information":[{"code":"300","type":"RC"},{"code":"81420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1248.64,"maximum":2960.29,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1248.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2917.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1387.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1387.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2960.29,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed ","code_information":[{"code":"369","type":"RC"},{"code":"37225","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"136","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1180.48,"maximum":1180.48,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1180.48,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC ","code_information":[{"code":"659","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15758.06,"maximum":15920.51,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":15758.06,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":15920.51,"methodology":"fee schedule"}]}]},{"description":"AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC ","code_information":[{"code":"268","type":"MS-DRG"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique ","code_information":[{"code":"305","type":"RC"},{"code":"87662","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.40,"maximum":200.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":197.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.11,"methodology":"fee schedule"}]}]},{"description":"Breast reconstruction ","code_information":[{"code":"T0004","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1257.98,"maximum":1270.95,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1257.98,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1270.95,"methodology":"fee schedule"}]}]},{"description":"Inj efgart-alfa 2mg hya-qv ","code_information":[{"code":"00723","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":32.87,"maximum":33.21,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":32.87,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":33.21,"methodology":"fee schedule"}]}]},{"description":"REHABILITATION WITH CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DEPRESSIVE NEUROSES  IPF","code_information":[{"code":"124","type":"RC"},{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1240.00,"maximum":1264.80,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1264.80,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1240.00,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Unlisted procedure, colon ","code_information":[{"code":"45399","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"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":"307","type":"RC"},{"code":"80420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":266.29,"maximum":631.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":266.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":622.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":295.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":295.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":631.33,"methodology":"fee schedule"}]}]},{"description":"Antibody; Treponema pallidum ","code_information":[{"code":"309","type":"RC"},{"code":"86780","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.78,"maximum":51.64,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.64,"methodology":"fee schedule"}]}]},{"description":"Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation ","code_information":[{"code":"20808","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":26605.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS ","code_information":[{"code":"112","type":"RC"},{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tenodesis of long tendon of biceps ","code_information":[{"code":"23430","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Oncology (hematolymphoid neoplasm), optical genome mapping for ocpy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically ","code_information":[{"code":"0413U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2078.51,"maximum":4927.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2078.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4857.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2309.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2309.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4927.77,"methodology":"fee schedule"}]}]},{"description":"TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot) ","code_information":[{"code":"302","type":"RC"},{"code":"81341","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.58,"maximum":193.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":190.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":193.40,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"409","type":"RC"},{"code":"74270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":781.69,"maximum":868.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":781.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":862.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":868.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":868.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":862.29,"methodology":"fee schedule"}]}]},{"description":"Secondary revision of orbitocraniofacial reconstruction ","code_information":[{"code":"21275","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH CC ","code_information":[{"code":"360","type":"RC"},{"code":"412","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Inflammation (eosinophilic esophagitis), ELISA analysis of eotaxin-3 (CCL26 [C-C motif chemokine ligand 26]) and major basic protein (PRG2 [proteoglycan 2, pro eosinophil major basic protein]), specim ","code_information":[{"code":"0095U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1269.91,"maximum":3010.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1269.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2967.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1411.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1411.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3010.72,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOT ","code_information":[{"code":"110","type":"RC"},{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guidance ","code_information":[{"code":"33019","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Drainage of subdiaphragmatic or subphrenic abscess, open ","code_information":[{"code":"361","type":"RC"},{"code":"49040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Excision of malignant tumor of maxilla or zygoma ","code_information":[{"code":"21034","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg ","code_information":[{"code":"J2354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.57,"maximum":2.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":1.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1.61,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2.17,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":0.99,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.12,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.57,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.58,"methodology":"fee schedule"}]}]},{"description":"Resection of external cardiac tumor ","code_information":[{"code":"33130","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC ","code_information":[{"code":"361","type":"RC"},{"code":"614","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Fine needle aspiration of orbital contents ","code_information":[{"code":"481","type":"RC"},{"code":"67415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Excision or fulguration; Skene's glands ","code_information":[{"code":"361","type":"RC"},{"code":"53270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure) ","code_information":[{"code":"409","type":"RC"},{"code":"74301","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":50.58,"maximum":56.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":50.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":56.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":56.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":55.79,"methodology":"fee schedule"}]}]},{"description":"CCND1/IGH (t(11;14)) (eg, mantle cell lymphoma) translocation analysis, major breakpoint, qualitative and quantitative, if performed ","code_information":[{"code":"305","type":"RC"},{"code":"81168","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":341.02,"maximum":808.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":341.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":796.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":808.51,"methodology":"fee schedule"}]}]},{"description":"Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access, including all imaging guidance, image documentation, an ","code_information":[{"code":"360","type":"RC"},{"code":"36584","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Revision of stapedectomy or stapedotomy ","code_information":[{"code":"69662","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Comparative analysis using Short Tandem Repeat (STR) markers; each additional specimen (eg, additional cord blood donor, additional fetal samples from different cultures, or additional zygosity in mul ","code_information":[{"code":"303","type":"RC"},{"code":"81266","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":501.41,"maximum":1188.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":501.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1171.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":557.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":557.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1188.76,"methodology":"fee schedule"}]}]},{"description":"Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon ","code_information":[{"code":"302","type":"RC"},{"code":"63681","type":"CDM"},{"code":"86480","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":101.96,"maximum":241.72,"gross_charge":963.75,"discounted_cash":963.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":101.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":238.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":113.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":113.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":241.72,"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":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Coronary artery bypass, vein only; 6 or more coronary venous grafts ","code_information":[{"code":"33516","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors, each ","code_information":[{"code":"306","type":"RC"},{"code":"86977","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Repair initial inguinal hernia, age 5 years or older; reducible ","code_information":[{"code":"361","type":"RC"},{"code":"49505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia ","code_information":[{"code":"27257","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC ","code_information":[{"code":"206","type":"RC"},{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation ","code_information":[{"code":"46910","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"PLEURAL EFFUSION WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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, innominate, ","code_information":[{"code":"35021","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOT ","code_information":[{"code":"134","type":"RC"},{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Hemoglobin; plasma ","code_information":[{"code":"83051","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12.02,"maximum":28.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.51,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia ","code_information":[{"code":"28635","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Removal of corneal epithelium; with application of chelating agent (eg, EDTA) ","code_information":[{"code":"65436","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"BONE DISEASES AND ARTHROPATHIES WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement ","code_information":[{"code":"E0785","type":"HCPCS"}],"standard_charges":[{"modifiers":"KF","modifiers_description":"Item designated by FDA as Class III device","setting":"outpatient","minimum":528.15,"maximum":1153.95,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":673.39,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1153.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":673.39,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":673.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":660.19,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":640.38,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":528.15,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":686.60,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":646.99,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":663.49,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":660.19,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":660.19,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":686.60,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; subclavian-vertebral ","code_information":[{"code":"35515","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age ","code_information":[{"code":"33985","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Red cell antigen (Yt blood group) genotyping (YT), gene analysis, ACHE (acetylcholinesterase (Cartwright blood group)) exon 2 ","code_information":[{"code":"0201U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"Repair fistula; oronasal ","code_information":[{"code":"30600","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and a ","code_information":[{"code":"499","type":"RC"},{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":18354.00,"maximum":32402.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18354.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":32402.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":32402.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Pooling of platelets or other blood products ","code_information":[{"code":"309","type":"RC"},{"code":"86965","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy ","code_information":[{"code":"360","type":"RC"},{"code":"60225","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio ","code_information":[{"code":"307","type":"RC"},{"code":"83661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.17,"maximum":85.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":84.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":85.76,"methodology":"fee schedule"}]}]},{"description":"Ultrasonic guidance, intraoperative ","code_information":[{"code":"329","type":"RC"},{"code":"76998","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":230.53,"maximum":256.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":230.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":254.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":256.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":256.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":254.30,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC ","code_information":[{"code":"206","type":"RC"},{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection, olanzapine, 0.5 mg ","code_information":[{"code":"J2359","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.83,"maximum":2.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":1.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1.75,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2.01,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2.01,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":0.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.04,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.04,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.91,"methodology":"fee schedule"}]}]},{"description":"Osteoplasty, facial bones; reduction ","code_information":[{"code":"21209","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy ","code_information":[{"code":"27151","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil ","code_information":[{"code":"0978T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; other vein ","code_information":[{"code":"36406","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Placement of amniotic membrane on the ocular surface; single layer, sutured ","code_information":[{"code":"65779","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; tibioperoneal trunk artery ","code_information":[{"code":"35304","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Level 2 Radiation Therapy ","code_information":[{"code":"5622","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":229.13,"maximum":500.62,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":292.14,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":500.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":292.14,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":292.14,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":286.41,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":229.13,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":297.87,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":287.84,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":286.41,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":286.41,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":297.87,"methodology":"fee schedule"}]}]},{"description":"Percutaneous portal vein catheterization by any method ","code_information":[{"code":"36481","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":2258.56,"payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft ","code_information":[{"code":"481","type":"RC"},{"code":"61608","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA/RNA), central nervous system pathogen, metagenomic next-generation sequencing , cerebrospinal fluid (CSF), identification of pathogenic bacteria, viruse ","code_information":[{"code":"0323U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3497.60,"maximum":8292.18,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3497.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8173.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3886.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3886.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8292.18,"methodology":"fee schedule"}]}]},{"description":"Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity ","code_information":[{"code":"83861","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":36.98,"maximum":87.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":86.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":41.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":87.67,"methodology":"fee schedule"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"208","type":"RC"},{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"305","type":"RC"},{"code":"81445","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":983.56,"maximum":2331.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":983.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2298.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1092.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1092.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2331.85,"methodology":"fee schedule"}]}]},{"description":"Injection, ecallantide, 1 mg ","code_information":[{"code":"J1290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":547.70,"maximum":1510.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":734.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":844.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":816.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":670.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":816.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1007.56,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1510.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1510.23,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":684.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":778.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":622.56,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":778.20,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":547.70,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":553.35,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin, quantitative, transcutaneous, per day; methemoglobin ","code_information":[{"code":"306","type":"RC"},{"code":"88741","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.41,"maximum":36.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.54,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"45389","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19023.00,"maximum":22929.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"description":"Esophagoscopy, flexible, transoral, with initial transendoscopic mechanical dilation (eg, nondrug-coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for esophageal s ","code_information":[{"code":"0884T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tongue base suspension, permanent suture technique ","code_information":[{"code":"369","type":"RC"},{"code":"41512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Ureteropyelostomy, anastomosis of ureter and renal pelvis ","code_information":[{"code":"50740","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection, anesthetic agent; sphenopalatine ganglion ","code_information":[{"code":"369","type":"RC"},{"code":"64505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"119","type":"RC"},{"code":"700","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment ","code_information":[{"code":"L3975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1438.50,"maximum":3142.95,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1834.09,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":3142.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1834.09,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1834.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1798.13,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1744.19,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1438.50,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1870.06,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1762.17,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1807.12,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1798.13,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1798.13,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1870.06,"methodology":"fee schedule"}]}]},{"description":"Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorect ","code_information":[{"code":"369","type":"RC"},{"code":"51721","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Ascorbic acid (Vitamin C), blood ","code_information":[{"code":"301","type":"RC"},{"code":"38164","type":"CDM"},{"code":"82180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.27,"maximum":38.57,"gross_charge":974.50,"discounted_cash":974.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":38.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":38.57,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique ","code_information":[{"code":"87580","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":32.98,"maximum":78.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.20,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CONCUSSION WITH CC ","code_information":[{"code":"089","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":29387.55,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":45568.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":40589.110,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":45568.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":45568.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7731.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7917.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":29387.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8797.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":31789.120,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":8676.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8797.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":23806.66,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":12976.33,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":8676.84,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":49116.240,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":54573.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":7581.48,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":15007.740,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":17061.070,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":13643.400,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":17061.070,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":30704.470,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8506.71,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":6805.37,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":19550.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":36148.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":19550.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":8846.98,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":64806.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":29060.440,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":18213.940,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8200.47,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":41817.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":8506.71,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":8506.71,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":8069.40,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":8761.91,"methodology":"fee schedule"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh ","code_information":[{"code":"15832","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC  IPF","code_information":[{"code":"136","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1531.28,"maximum":1531.28,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1531.28,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"Radiologic examination; forearm, 2 views ","code_information":[{"code":"321","type":"RC"},{"code":"73090","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":38.70,"maximum":43.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":38.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":42.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":43.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":43.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":42.70,"methodology":"fee schedule"}]}]},{"description":"Pericardiocentesis, including imaging guidance, when performed ","code_information":[{"code":"33016","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), ","code_information":[{"code":"34705","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"210","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) ","code_information":[{"code":"360","type":"RC"},{"code":"43249","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Biopsy external auditory canal ","code_information":[{"code":"481","type":"RC"},{"code":"69105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"45346","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), initial site ","code_information":[{"code":"311","type":"RC"},{"code":"88333","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1079.37,"maximum":2558.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1079.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2522.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2558.98,"methodology":"fee schedule"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent ","code_information":[{"code":"499","type":"RC"},{"code":"68815","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"HYPERTENSION WITHOUT MCC ","code_information":[{"code":"203","type":"RC"},{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children ","code_information":[{"code":"15115","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Bone-material quality testing by microindentation(s) of the tibia(s), with results reported as a score ","code_information":[{"code":"0547T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"50081","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Catecholamines; fractionated ","code_information":[{"code":"302","type":"RC"},{"code":"82384","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.54,"maximum":98.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":41.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":97.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":46.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":46.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":98.47,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC  IPF","code_information":[{"code":"056","type":"MS-DRG"},{"code":"126","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1113.66,"maximum":1113.66,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1113.66,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH CC ","code_information":[{"code":"158","type":"RC"},{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); ","code_information":[{"code":"27496","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique ","code_information":[{"code":"303","type":"RC"},{"code":"87486","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Application, cast; hand and lower forearm (gauntlet) ","code_information":[{"code":"29085","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Antibody screen, RBC, each serum technique ","code_information":[{"code":"305","type":"RC"},{"code":"86850","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.07,"maximum":38.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":38.10,"methodology":"fee schedule"}]}]},{"description":"Culture, typing; other methods ","code_information":[{"code":"87158","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12.73,"maximum":30.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":29.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":30.19,"methodology":"fee schedule"}]}]},{"description":"Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon ","code_information":[{"code":"26370","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":" Labor Room/Delivery Birthing Center  ","code_information":[{"code":"724","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1716.00,"maximum":3637.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1716.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3637.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1907.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1907.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3637.00,"methodology":"case rate"}]}]},{"description":"Amino acids; multiple, qualitative, each specimen ","code_information":[{"code":"303","type":"RC"},{"code":"82128","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.82,"maximum":54.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":54.09,"methodology":"fee schedule"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITH CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"121","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thrombin time; titer ","code_information":[{"code":"306","type":"RC"},{"code":"85675","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.27,"maximum":26.71,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":26.71,"methodology":"fee schedule"}]}]},{"description":"Protein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF) ","code_information":[{"code":"84166","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.26,"maximum":75.94,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":15.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":18.19,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":31.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":75.94,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":75.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":18.19,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":18.19,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":57.82,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":65.71,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":52.57,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":65.71,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":50.37,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":17.83,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":17.89,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":14.26,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":18.54,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":18.07,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":17.92,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":17.83,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":17.83,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":16.35,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":18.54,"methodology":"fee schedule"}]}]},{"description":"Disarticulation of shoulder; secondary closure or scar revision ","code_information":[{"code":"23921","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"EPISTAXIS WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Urea nitrogen; semiquantitative (eg, reagent strip test) ","code_information":[{"code":"304","type":"RC"},{"code":"84525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.44,"maximum":20.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20.01,"methodology":"fee schedule"}]}]},{"description":"Dissection, deep jugular node(s) ","code_information":[{"code":"38542","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA) ","code_information":[{"code":"0176U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":105.59,"maximum":250.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":105.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":246.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":117.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":117.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":250.34,"methodology":"fee schedule"}]}]},{"description":"Cerebrospinal fluid leakage detection and localization ","code_information":[{"code":"341","type":"RC"},{"code":"78650","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1265.98,"maximum":1406.37,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1265.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1396.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1406.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1406.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1396.52,"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":"306","type":"RC"},{"code":"81110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":201.05,"maximum":476.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":201.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":469.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":476.66,"methodology":"fee schedule"}]}]},{"description":"Application of halo, including removal; cranial ","code_information":[{"code":"20661","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Transposition and/or reimplantation; vertebral to subclavian artery ","code_information":[{"code":"35693","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":" Ambulatory Surgical Care Other  Minor","code_information":[{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"MVP Health Plan","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","estimated_amount":1949.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."}]}]},{"description":"Vasoactive intestinal peptide (VIP) ","code_information":[{"code":"306","type":"RC"},{"code":"84586","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":58.12,"maximum":137.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":58.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":135.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":137.79,"methodology":"fee schedule"}]}]},{"description":"Application of short leg cast (below knee to toes); walking or ambulatory type ","code_information":[{"code":"29425","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"100","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cystourethroscopy (including ureteral catheterization); with fragmentation of ureteral calculus (eg, ultrasonic or electro-hydraulic technique) ","code_information":[{"code":"490","type":"RC"},{"code":"52325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Neurology (mild cognitive impairment), analysis of b-amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive, or negative ","code_information":[{"code":"0358U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":428.52,"maximum":1015.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":428.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1001.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":476.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":476.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1015.95,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material; ","code_information":[{"code":"400","type":"RC"},{"code":"75557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1452.00,"maximum":1613.02,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1452.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1601.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1613.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1613.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1601.72,"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); without c ","code_information":[{"code":"70557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4654.13,"maximum":5817.74,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":5119.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5817.74,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":4654.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5817.74,"methodology":"fee schedule"}]}]},{"description":"Gastrectomy, partial, distal; with gastrojejunostomy ","code_information":[{"code":"43632","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":32.98,"maximum":78.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.20,"methodology":"fee schedule"}]}]},{"description":"Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or ","code_information":[{"code":"0421T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"HIV WITH OR WITHOUT OTHER RELATED CONDITION ","code_information":[{"code":"101","type":"RC"},{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"212","type":"RC"},{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed ","code_information":[{"code":"37221","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":26605.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Arthroplasty, ankle; with implant (total ankle) ","code_information":[{"code":"27702","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28614.00,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthroscopy, shoulder, surgical; synovectomy, complete ","code_information":[{"code":"29821","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC ","code_information":[{"code":"214","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis ","code_information":[{"code":"0170U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2886.97,"maximum":6844.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2886.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6746.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6844.50,"methodology":"fee schedule"}]}]},{"description":"CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, nonduplicated gene when duplication/multiplication is trans) (List s ","code_information":[{"code":"0074U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":741.75,"maximum":1758.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":741.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1733.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":824.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":824.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1758.55,"methodology":"fee schedule"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"126","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1180.48,"maximum":1180.48,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1180.48,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Portoenterostomy (eg, Kasai procedure) ","code_information":[{"code":"47701","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"164","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"C-reactive protein; ","code_information":[{"code":"300","type":"RC"},{"code":"86140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.52,"maximum":20.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20.20,"methodology":"fee schedule"}]}]},{"description":"Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent ","code_information":[{"code":"30906","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Drug metabolism (eg, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis ","code_information":[{"code":"81418","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1508.60,"maximum":3576.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1508.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3525.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1676.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1676.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3576.61,"methodology":"fee schedule"}]}]},{"description":"Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an ","code_information":[{"code":"B4162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3.86,"maximum":4.82,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4.82,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3.86,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4.82,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique ","code_information":[{"code":"303","type":"RC"},{"code":"87528","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.98,"maximum":78.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.20,"methodology":"fee schedule"}]}]},{"description":"Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision ","code_information":[{"code":"310","type":"RC"},{"code":"88166","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.92,"maximum":59.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":58.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":59.09,"methodology":"fee schedule"}]}]},{"description":"Galactose-1-phosphate uridyl transferase; screen ","code_information":[{"code":"300","type":"RC"},{"code":"82776","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.31,"maximum":45.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":45.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45.79,"methodology":"fee schedule"}]}]},{"description":"Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated or stra ","code_information":[{"code":"490","type":"RC"},{"code":"49492","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthroscopy, elbow, surgical; debridement, limited ","code_information":[{"code":"29837","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19») antibody, quantitative ","code_information":[{"code":"305","type":"RC"},{"code":"86413","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":69.45,"maximum":164.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":69.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":162.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":77.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":77.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":164.66,"methodology":"fee schedule"}]}]},{"description":"Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle ","code_information":[{"code":"19307","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis ","code_information":[{"code":"300","type":"RC"},{"code":"81302","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":868.35,"maximum":2058.69,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":868.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2029.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":964.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":964.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2058.69,"methodology":"fee schedule"}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT ","code_information":[{"code":"014","type":"MS-DRG"},{"code":"141","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments ","code_information":[{"code":"22804","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":26605.10,"maximum":83200.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":67500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":75000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":75000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction ","code_information":[{"code":"24505","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy) ","code_information":[{"code":"32669","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Ileoscopy, through stoma; with transendoscopic balloon dilation ","code_information":[{"code":"44381","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC ","code_information":[{"code":"145","type":"RC"},{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"116","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1074.58,"maximum":1074.58,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1074.58,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"HEART FAILURE AND SHOCK WITH CC ","code_information":[{"code":"210","type":"RC"},{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) ","code_information":[{"code":"305","type":"RC"},{"code":"83701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.70,"maximum":132.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":130.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":61.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":61.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":132.05,"methodology":"fee schedule"}]}]},{"description":"NON-EXTENSIVE BURNS ","code_information":[{"code":"135","type":"RC"},{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of proximal fibula or shaft fracture; without manipulation ","code_information":[{"code":"27780","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) ","code_information":[{"code":"43752","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Removal of tongs or halo applied by another individual ","code_information":[{"code":"20665","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Oncology (colorectal) screening,quantitative real-time target and signal amplification,methylated DNA markers,incl LASS4,LRRC4 and PPP24RC,a reference marker ZDHHC1,and a protein marker (fecal hemoglo ","code_information":[{"code":"0464U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":973.71,"maximum":2308.49,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":973.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2275.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1082.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1082.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2308.49,"methodology":"fee schedule"}]}]},{"description":"Relocation of skin pocket for implanted cardiac contractility modulation-defibrillation pulse generator ","code_information":[{"code":"0925T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Closed treatment of greater humeral tuberosity fracture; with manipulation ","code_information":[{"code":"23625","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Bypass graft, with vein; aortobi-iliac ","code_information":[{"code":"35538","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Replace proximal and distal upright for kafo ","code_information":[{"code":"L4070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":283.95,"maximum":620.40,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":362.04,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":620.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":362.04,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":362.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":354.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":344.29,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":283.95,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":369.14,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":347.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":356.71,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":354.94,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":354.94,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":369.14,"methodology":"fee schedule"}]}]},{"description":"Application, cast; shoulder to hand (long arm) ","code_information":[{"code":"29065","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Dressing change (for other than burns) under anesthesia (other than local) ","code_information":[{"code":"15852","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Infectious disease (fungi), fungal pathogen identification, DNA (15 fungal targets), blood culture, amplified probe technique, each target reported as detected or not detected ","code_information":[{"code":"0140U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":257.85,"maximum":611.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":257.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":602.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":286.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":286.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":611.32,"methodology":"fee schedule"}]}]},{"description":"Blood count; spun microhematocrit ","code_information":[{"code":"306","type":"RC"},{"code":"85013","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.52,"maximum":27.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":27.30,"methodology":"fee schedule"}]}]},{"description":"Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"57180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal r ","code_information":[{"code":"25116","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"NEUROSES EXCEPT DEPRESSIVE  IPF","code_information":[{"code":"114","type":"RC"},{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1531.28,"maximum":1561.91,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1561.91,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1531.28,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"66770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) ","code_information":[{"code":"31641","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, surgical; with lobectomy (single lobe) ","code_information":[{"code":"32663","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Excision or fulguration; urethral polyp(s), distal urethra ","code_information":[{"code":"361","type":"RC"},{"code":"53260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"136","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed) ","code_information":[{"code":"22610","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11152.90,"maximum":83200.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":54000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":60000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":60000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately ","code_information":[{"code":"402","type":"RC"},{"code":"76802","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":108.56,"maximum":120.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":108.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":119.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":120.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":120.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":119.75,"methodology":"fee schedule"}]}]},{"description":"Incision of labial frenum (frenotomy) ","code_information":[{"code":"40806","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Blood count; automated differential WBC count ","code_information":[{"code":"305","type":"RC"},{"code":"85004","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.64,"maximum":25.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":24.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":25.23,"methodology":"fee schedule"}]}]},{"description":"Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral ","code_information":[{"code":"32097","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) ","code_information":[{"code":"369","type":"RC"},{"code":"58200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRN ","code_information":[{"code":"81430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1300.00,"maximum":6920.55,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1657.50,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2840.34,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":6920.55,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6918.44,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1657.50,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1657.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4743.21,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":5389.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":4312.10,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":5389.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":4131.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1625.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1300.00,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1690.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1633.12,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1625.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1625.00,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1690.00,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion, conjunctiva; up to 1 cm ","code_information":[{"code":"499","type":"RC"},{"code":"68110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"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":"87449","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.71,"maximum":46.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.72,"methodology":"fee schedule"}]}]},{"description":"Lactose, urine, qualitative ","code_information":[{"code":"83633","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18.51,"maximum":43.88,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":43.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":20.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":20.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":43.88,"methodology":"fee schedule"}]}]},{"description":"Biopsy of intestine by capsule, tube, peroral (1 or more specimens) ","code_information":[{"code":"44100","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately ","code_information":[{"code":"369","type":"RC"},{"code":"63086","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"320","type":"RC"},{"code":"73202","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1012.53,"maximum":1124.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1012.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1116.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1124.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1124.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1116.93,"methodology":"fee schedule"}]}]},{"description":"Antibody; HIV-2 ","code_information":[{"code":"307","type":"RC"},{"code":"86702","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.24,"maximum":52.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.73,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"320","type":"RC"},{"code":"74170","type":"CPT"}],"standard_charges":[{"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":1037.41,"maximum":1152.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1037.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1144.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1152.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1152.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1144.38,"methodology":"fee schedule"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"126","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transmitting coil and cable, integrated, for use with cochlear implant device, replacement ","code_information":[{"code":"L8629","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":168.77,"maximum":368.74,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":215.18,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":368.74,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":215.18,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":215.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":210.96,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":204.63,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":168.77,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":219.40,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":206.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":212.01,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":210.96,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":210.96,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":219.40,"methodology":"fee schedule"}]}]},{"description":"Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); ","code_information":[{"code":"309","type":"RC"},{"code":"86152","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":412.53,"maximum":978.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":412.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":964.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":458.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":458.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":978.04,"methodology":"fee schedule"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC ","code_information":[{"code":"068","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"101","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis ","code_information":[{"code":"44202","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair recurrent femoral hernia; incarcerated or strangulated ","code_information":[{"code":"49557","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"AFTERCARE WITH CC/MCC ","code_information":[{"code":"156","type":"RC"},{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, i ","code_information":[{"code":"481","type":"RC"},{"code":"62320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint ","code_information":[{"code":"26676","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC ","code_information":[{"code":"520","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":34690.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":102373.580,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":91186.050,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":102373.580,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":102373.580,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10335.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22743.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":25270.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25270.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":71416.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":11798.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25270.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":25270.00,"methodology":"case rate"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":17645.50,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":11798.96,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":110342.780,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":122603.090,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":10134.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":33715.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":38328.790,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":30650.770,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":38328.790,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":68979.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":11567.61,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9254.09,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":43922.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":81209.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":43922.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12030.31,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":145591.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":65286.140,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":40918.780,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11151.18,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":93944.620,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11567.61,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":11567.61,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":10786.54,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":11914.64,"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"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision dermoid cyst, nose; simple, skin, subcutaneous ","code_information":[{"code":"30124","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC ","code_information":[{"code":"361","type":"RC"},{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Ankle disarticulation ","code_information":[{"code":"27889","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Incision and drainage, perianal abscess, superficial ","code_information":[{"code":"369","type":"RC"},{"code":"46050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"126","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1094.67,"maximum":1094.67,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1094.67,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Neuro Inh Ataxia Genomic DNA Seq Alys 12 Bld/Slv ","code_information":[{"code":"0216U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2528.40,"maximum":5994.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2528.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5908.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2809.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2809.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5994.38,"methodology":"fee schedule"}]}]},{"description":"Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar ","code_information":[{"code":"22862","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Skeletal muscle relaxants; 3 or more ","code_information":[{"code":"80370","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.75,"maximum":46.64,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_percentage":41.30,"standard_charge_algorithm":"Reimbursement will be 41.3% of billable gross charges.","estimated_amount":309.640,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":47.60,"standard_charge_algorithm":"Reimbursement will be 47.6% of billable gross charges.","estimated_amount":356.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":41.04,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":46.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":37.31,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":46.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":35.75,"methodology":"fee schedule"}]}]},{"description":"Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transuret ","code_information":[{"code":"360","type":"RC"},{"code":"52648","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy ","code_information":[{"code":"369","type":"RC"},{"code":"C7533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"72149","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":996.80,"maximum":1107.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":996.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1099.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1107.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1107.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1099.58,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"212","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER FACTORS INFLUENCING HEALTH STATUS ","code_information":[{"code":"214","type":"RC"},{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Ureteroneocystostomy; with extensive ureteral tailoring ","code_information":[{"code":"50783","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Closure of single ventricular septal defect, with or without patch; with pulmonary valvotomy or infundibular resection (acyanotic) ","code_information":[{"code":"33684","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg ","code_information":[{"code":"37760","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Luteinizing releasing factor (LRH) ","code_information":[{"code":"83727","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28.28,"maximum":67.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67.04,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS ","code_information":[{"code":"124","type":"RC"},{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Rare DS Whl Xom & Mitochdrl DNA Seq Alys Proband ","code_information":[{"code":"0214U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8594.47,"maximum":20375.94,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8594.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":20083.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9550.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9550.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20375.94,"methodology":"fee schedule"}]}]},{"description":"Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) ","code_information":[{"code":"304","type":"RC"},{"code":"86689","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.83,"maximum":75.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":74.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":75.47,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; aortorenal ","code_information":[{"code":"35560","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application ","code_information":[{"code":"31643","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Radiologic examination; clavicle, complete ","code_information":[{"code":"323","type":"RC"},{"code":"73000","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":40.45,"maximum":44.94,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":44.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":44.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":44.62,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during cours ","code_information":[{"code":"37188","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Closed treatment of sesamoid fracture ","code_information":[{"code":"28530","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus ","code_information":[{"code":"361","type":"RC"},{"code":"51065","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Closure of laceration, vestibule of mouth; over 2.5 cm or complex ","code_information":[{"code":"369","type":"RC"},{"code":"40831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"BRONCHITIS AND ASTHMA WITH CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy ","code_information":[{"code":"361","type":"RC"},{"code":"57250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography ","code_information":[{"code":"23350","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insertion of new or replacement of permanent pacemaker with atrial transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertio ","code_information":[{"code":"790","type":"RC"},{"code":"C7537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft ","code_information":[{"code":"369","type":"RC"},{"code":"66184","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"156","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1195.10,"maximum":1195.10,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1195.10,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performed ","code_information":[{"code":"27066","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies ","code_information":[{"code":"30462","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC ","code_information":[{"code":"074","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Clotting inhibitors or anticoagulants; antithrombin III, antigen assay ","code_information":[{"code":"85301","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.78,"maximum":42.16,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":41.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":42.16,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of interphalangeal joint dislocation; without anesthesia ","code_information":[{"code":"28660","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Prostate specific antigen (PSA); free ","code_information":[{"code":"309","type":"RC"},{"code":"84154","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.25,"maximum":71.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":70.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":71.72,"methodology":"fee schedule"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerus ","code_information":[{"code":"24140","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Nephrology (chronic kidney disease), apolipoprotein A4, CD5 antigen-like, and insulin-like growth factor binding protein 3 by enzyme-linked immunoassay, plasma, algorithm, combining results with HDL, ","code_information":[{"code":"0385U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":642.78,"maximum":1523.92,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":642.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1502.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":714.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":714.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1523.92,"methodology":"fee schedule"}]}]},{"description":"Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna ","code_information":[{"code":"25375","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Injection procedure for temporomandibular joint arthrography ","code_information":[{"code":"21116","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Aortic hemiarch graft including isolation and control of the arch vessels, beveled open distal aortic anastomosis extending under one or more of the arch vessels, and total circulatory arrest or isola ","code_information":[{"code":"33866","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands ","code_information":[{"code":"52214","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar ","code_information":[{"code":"361","type":"RC"},{"code":"63282","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Complete repair tetralogy of Fallot with pulmonary atresia including construction of conduit from right ventricle to pulmonary artery and closure of ventricular septal defect ","code_information":[{"code":"33697","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"75984","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":487.01,"maximum":541.02,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":487.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":537.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":541.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":541.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":537.23,"methodology":"fee schedule"}]}]},{"description":"Ureteropyelostomy, anastomosis of ureter and renal pelvis ","code_information":[{"code":"361","type":"RC"},{"code":"50740","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft) ","code_information":[{"code":"27357","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap) ","code_information":[{"code":"39561","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"154","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"208","type":"RC"},{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views ","code_information":[{"code":"321","type":"RC"},{"code":"71111","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":77.41,"maximum":85.99,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":77.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":85.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":85.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":85.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":85.39,"methodology":"fee schedule"}]}]},{"description":"Culture, bacterial; quantitative colony count, urine ","code_information":[{"code":"304","type":"RC"},{"code":"87086","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.28,"maximum":31.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":31.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":31.47,"methodology":"fee schedule"}]}]},{"description":"Fat differential, feces, quantitative ","code_information":[{"code":"304","type":"RC"},{"code":"82715","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.79,"maximum":89.58,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":37.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":88.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":41.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":89.58,"methodology":"fee schedule"}]}]},{"description":"Thoracotomy; with removal of intrapulmonary foreign body ","code_information":[{"code":"32151","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Excision of intracardiac tumor, resection with cardiopulmonary bypass ","code_information":[{"code":"33120","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"134","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"200","type":"RC"},{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"149","type":"RC"},{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Insertion of Thomas shunt (separate procedure) ","code_information":[{"code":"36835","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Urography (pyelography), intravenous, with or without KUB, with or without tomography ","code_information":[{"code":"329","type":"RC"},{"code":"74400","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":114.62,"maximum":127.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":114.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":126.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":127.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":127.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":126.44,"methodology":"fee schedule"}]}]},{"description":"Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping ","code_information":[{"code":"0260U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2078.51,"maximum":4927.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2078.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4857.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2309.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2309.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4927.77,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with removal of foreign body(s) ","code_information":[{"code":"369","type":"RC"},{"code":"43215","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Trypsin; duodenal fluid ","code_information":[{"code":"306","type":"RC"},{"code":"84485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.84,"maximum":28.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":27.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.08,"methodology":"fee schedule"}]}]},{"description":"FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability ºXLID») gene analysis; characterization of alleles (eg, expanded size and promoter methylation ","code_information":[{"code":"77484","type":"CDM"},{"code":"81244","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.91,"maximum":191.19,"gross_charge":236.00,"discounted_cash":236.00,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":39.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":45.79,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":78.46,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":191.19,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":191.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":45.79,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":45.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":131.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":148.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":119.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":148.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":114.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":44.89,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":35.91,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":46.69,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":45.11,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":44.89,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":44.89,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":41.16,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":46.69,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"PLEURAL EFFUSION WITHOUT CC/MCC ","code_information":[{"code":"147","type":"RC"},{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Exploration of penetrating wound (separate procedure); chest ","code_information":[{"code":"20101","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Immune complex assay ","code_information":[{"code":"86332","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":40.09,"maximum":95.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":93.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":44.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":44.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":95.04,"methodology":"fee schedule"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS ","code_information":[{"code":"154","type":"RC"},{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"118","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu ","drug_information":{"unit":"1500","type":"UN"},"code_information":[{"code":"72834","type":"CDM"},{"code":"J2791","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.73,"maximum":13.11,"gross_charge":1848.00,"discounted_cash":1848.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":5.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8.52,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13.11,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13.11,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":5.95,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":6.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":5.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":6.76,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":4.73,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":4.78,"methodology":"fee schedule"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar ","code_information":[{"code":"22214","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) ","code_information":[{"code":"36831","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs ","code_information":[{"code":"15610","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Coronary artery bypass, vein only; 4 coronary venous grafts ","code_information":[{"code":"33513","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of ankle implant ","code_information":[{"code":"27704","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) ","code_information":[{"code":"23420","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, anterior segment of eye ","code_information":[{"code":"66999","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) ","code_information":[{"code":"481","type":"RC"},{"code":"57109","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":12033.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugated hyperbilirubinemia ºGilbert syndrome») gene analysis, common variants (eg, *28, *36, *37) ","code_information":[{"code":"81350","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":384.93,"maximum":912.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":384.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":899.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":427.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":427.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":912.60,"methodology":"fee schedule"}]}]},{"description":"Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, w ","code_information":[{"code":"360","type":"RC"},{"code":"50437","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Radiologic examination, abdomen; 2 views ","code_information":[{"code":"409","type":"RC"},{"code":"74019","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":191.88,"maximum":213.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":191.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":211.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":213.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":213.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":211.66,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC ","code_information":[{"code":"212","type":"RC"},{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Decompression facial nerve, intratemporal; lateral to geniculate ganglion ","code_information":[{"code":"69720","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging repo ","code_information":[{"code":"329","type":"RC"},{"code":"76015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":276.48,"maximum":307.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":276.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":304.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":307.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":307.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":304.99,"methodology":"fee schedule"}]}]},{"description":"Xenon xe-133 gas, diagnostic, per 10 millicuries ","drug_information":{"unit":"10","type":"UN"},"code_information":[{"code":"60837","type":"CDM"},{"code":"A9558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":273.98,"maximum":697.86,"gross_charge":400.25,"discounted_cash":400.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":364.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":352.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":289.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":352.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":434.88,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":697.86,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":697.86,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":301.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":342.47,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":273.98,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":342.47,"methodology":"fee schedule"}]}]},{"description":"Injection trabectedin 0.1m ","code_information":[{"code":"09480","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":379.34,"maximum":383.25,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":379.34,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":383.25,"methodology":"fee schedule"}]}]},{"description":"SINUS AND MASTOID PROCEDURES WITH CC/MCC ","code_information":[{"code":"135","type":"MS-DRG"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"External breast prosthesis garment, with mastectomy form, post mastectomy ","code_information":[{"code":"L8015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":56.51,"maximum":123.47,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":72.05,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":123.47,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":72.05,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":72.05,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":70.64,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":68.52,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":56.51,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":73.47,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":69.23,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":70.99,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":70.64,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":70.64,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":73.47,"methodology":"fee schedule"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"156","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1247.30,"maximum":1247.30,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1247.30,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Reptilase test ","code_information":[{"code":"301","type":"RC"},{"code":"85635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.20,"maximum":38.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":38.41,"methodology":"fee schedule"}]}]},{"description":"Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets, amplified probe technique, including multiplex reverse transcription for RNA ","code_information":[{"code":"0115U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":452.95,"maximum":1073.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":452.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1058.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":503.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":503.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1073.87,"methodology":"fee schedule"}]}]},{"description":"Galactose-1-phosphate uridyl transferase; quantitative ","code_information":[{"code":"82775","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.86,"maximum":89.76,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":18.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":36.83,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":89.76,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":89.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":21.49,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":68.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":77.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":62.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":77.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":59.52,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":21.07,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":21.14,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":16.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":21.91,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":21.35,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21.18,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":21.07,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":21.07,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":19.32,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":21.91,"methodology":"fee schedule"}]}]},{"description":"Bilirubin; feces, qualitative ","code_information":[{"code":"309","type":"RC"},{"code":"82252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.50,"maximum":17.78,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17.78,"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Krukenberg procedure ","code_information":[{"code":"25915","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor, shaft or distal humerus ","code_information":[{"code":"24150","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, hand; minimum of 3 views ","code_information":[{"code":"321","type":"RC"},{"code":"73130","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":42.10,"maximum":46.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":42.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":46.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":46.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.44,"methodology":"fee schedule"}]}]},{"description":"Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) ","code_information":[{"code":"481","type":"RC"},{"code":"54235","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair initial femoral hernia, any age; incarcerated or strangulated ","code_information":[{"code":"360","type":"RC"},{"code":"49553","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the ","code_information":[{"code":"37249","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method ","code_information":[{"code":"360","type":"RC"},{"code":"58662","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5197.25,"maximum":12321.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5197.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":12144.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5775.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5775.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12321.74,"methodology":"fee schedule"}]}]},{"description":"Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger than 12 years of age ","code_information":[{"code":"31551","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"111","type":"RC"},{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization of urethra ","code_information":[{"code":"490","type":"RC"},{"code":"54326","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Pinworm exam (eg, cellophane tape prep) ","code_information":[{"code":"87172","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7.02,"maximum":16.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.65,"methodology":"fee schedule"}]}]},{"description":"Quantitation of therapeutic drug, not elsewhere specified ","code_information":[{"code":"80299","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30.66,"maximum":72.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":71.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":72.70,"methodology":"fee schedule"}]}]},{"description":"Neurectomy, popliteal (gastrocnemius) ","code_information":[{"code":"27326","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Cyanocobalamin (Vitamin B-12); unsaturated binding capacity ","code_information":[{"code":"82608","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":23.56,"maximum":55.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":55.85,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"099","type":"MS-DRG"},{"code":"145","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous defibrillation lead only ","code_information":[{"code":"0921T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Culture, bacterial; quantitative colony count, urine ","code_information":[{"code":"305","type":"RC"},{"code":"87086","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.28,"maximum":31.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":31.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":31.47,"methodology":"fee schedule"}]}]},{"description":"Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter ","code_information":[{"code":"490","type":"RC"},{"code":"61215","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":27338.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15602.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":27338.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17336.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17336.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":27338.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"156","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1180.48,"maximum":1180.48,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1180.48,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use ","code_information":[{"code":"90672","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.72,"maximum":73.59,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":41.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":33.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":49.74,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":73.59,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":73.59,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":33.80,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":38.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":30.72,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":38.41,"methodology":"fee schedule"}]}]},{"description":"Mastoidectomy; modified radical ","code_information":[{"code":"481","type":"RC"},{"code":"69505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code) ","code_information":[{"code":"15854","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision dermoid cyst, nose; simple, skin, subcutaneous ","code_information":[{"code":"30124","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Hepatitis Be antibody (HBeAb) ","code_information":[{"code":"300","type":"RC"},{"code":"86707","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.03,"maximum":45.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45.12,"methodology":"fee schedule"}]}]},{"description":"Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) ","code_information":[{"code":"499","type":"RC"},{"code":"53442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Thyrotropin releasing hormone (TRH) stimulation panel; 2 hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 4) ","code_information":[{"code":"305","type":"RC"},{"code":"80439","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":110.56,"maximum":262.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":110.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":258.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":122.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":122.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":262.12,"methodology":"fee schedule"}]}]},{"description":"Replantation, penis, complete amputation including urethral repair ","code_information":[{"code":"54438","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during ","code_information":[{"code":"360","type":"RC"},{"code":"37213","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) ","code_information":[{"code":"309","type":"RC"},{"code":"81335","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":287.56,"maximum":681.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":287.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":671.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":319.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":319.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":681.76,"methodology":"fee schedule"}]}]},{"description":"Hemorrhoidectomy, internal and external, 2 or more columns/groups; ","code_information":[{"code":"46260","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Sodium; urine ","code_information":[{"code":"300","type":"RC"},{"code":"84300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.32,"maximum":19.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.73,"methodology":"fee schedule"}]}]},{"description":"Varicella-zoster immune globulin, human, for intramuscular use ","code_information":[{"code":"90396","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2461.31,"maximum":6556.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2848.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3273.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3164.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":2601.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3164.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3906.80,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":6556.10,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6556.10,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":2707.75,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":3076.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":2461.31,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":3076.64,"methodology":"fee schedule"}]}]},{"description":"FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence ","code_information":[{"code":"81286","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":219.86,"maximum":1170.45,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":244.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":480.38,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1170.45,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1170.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":802.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":911.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":729.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":911.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":698.76,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":219.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":285.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":276.20,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":251.99,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":285.82,"methodology":"fee schedule"}]}]},{"description":"Catheterization for collection of specimen, single patient, all places of service ","code_information":[{"code":"306","type":"RC"},{"code":"P9612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.94,"maximum":11.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":11.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":11.70,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Antibody; Leishmania ","code_information":[{"code":"302","type":"RC"},{"code":"86717","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.15,"maximum":47.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":47.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47.77,"methodology":"fee schedule"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC ","code_information":[{"code":"040","type":"MS-DRG"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"135","type":"RC"},{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene ","code_information":[{"code":"0009U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":176.02,"maximum":417.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":176.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":411.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":195.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":195.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":417.30,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique ","code_information":[{"code":"303","type":"RC"},{"code":"87480","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.98,"maximum":78.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.20,"methodology":"fee schedule"}]}]},{"description":"Neuroplasty and/or transposition; ulnar nerve at wrist ","code_information":[{"code":"64719","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Shortening of tendon, extensor, hand or finger, each tendon ","code_information":[{"code":"26477","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"116","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1276.73,"maximum":1276.73,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1276.73,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; 3 cm or greater ","code_information":[{"code":"26118","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Removal or revision of sling for stress incontinence (eg, fascia or synthetic) ","code_information":[{"code":"361","type":"RC"},{"code":"57287","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Blood count; reticulocyte, manual ","code_information":[{"code":"301","type":"RC"},{"code":"85044","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.09,"maximum":16.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.81,"methodology":"fee schedule"}]}]},{"description":"Repositioning of percutaneous right or left heart ventricular assist device with imaging guidance at separate and distinct session from insertion ","code_information":[{"code":"33993","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical ","code_information":[{"code":"324","type":"RC"},{"code":"72156","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":1135.12,"maximum":1261.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1135.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1252.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1261.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1261.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1252.16,"methodology":"fee schedule"}]}]},{"description":"Tissue transglutaminase, each immunoglobulin (Ig) class ","code_information":[{"code":"86364","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18.97,"maximum":44.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":44.97,"methodology":"fee schedule"}]}]},{"description":"MAJOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"125","type":"RC"},{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MINOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"360","type":"RC"},{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"201","type":"RC"},{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm ","code_information":[{"code":"11621","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Carbamazepine; total ","code_information":[{"code":"304","type":"RC"},{"code":"80156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.97,"maximum":56.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":56.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.82,"methodology":"fee schedule"}]}]},{"description":" Emergency Room General Classification  ","code_information":[{"code":"450","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":211.00,"maximum":800.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":211.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":425.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":234.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":234.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":425.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":800.00,"methodology":"case rate"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":360.00,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":1424.560,"methodology":"percent of total billed charges"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":1525.030,"methodology":"percent of total billed charges"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":2289.000,"methodology":"percent of total billed charges"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":1525.030,"methodology":"percent of total billed charges"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":46.89,"standard_charge_algorithm":"Reimbursement will be 46.89% of billable gross charges.","estimated_amount":2422.130,"methodology":"percent of total billed charges"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) ","code_information":[{"code":"323","type":"RC"},{"code":"72147","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1433.91,"maximum":1592.92,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1433.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1581.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1592.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1592.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1581.76,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and a ","code_information":[{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":50123.00,"maximum":59838.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":50123.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":59838.00,"methodology":"case rate"}]}]},{"description":"PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor ºGIST»), gene analysis, targeted sequence analysis (eg, exons 12, 18) ","code_information":[{"code":"303","type":"RC"},{"code":"81314","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":542.04,"maximum":1285.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":542.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1266.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1285.09,"methodology":"fee schedule"}]}]},{"description":"Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, closure of Hartmann type procedure) ","code_information":[{"code":"44626","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve ","code_information":[{"code":"0440T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); REDUCIBLE (SEPARATE PROCEDURE) ","code_information":[{"code":"361","type":"RC"},{"code":"49570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_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":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) ","code_information":[{"code":"21188","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Neurectomy, intrinsic musculature of foot ","code_information":[{"code":"28055","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including s ","code_information":[{"code":"19081","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Repair of iris, ciliary body (as for iridodialysis) ","code_information":[{"code":"369","type":"RC"},{"code":"66680","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Open treatment of sternum fracture with or without skeletal fixation ","code_information":[{"code":"21825","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG ºany form»), utilizing maternal serum, algorithm reported as a risk score ","code_information":[{"code":"305","type":"RC"},{"code":"81510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":91.36,"maximum":216.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":91.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":213.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":101.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":101.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":216.61,"methodology":"fee schedule"}]}]},{"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":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; with cyclectomy ","code_information":[{"code":"499","type":"RC"},{"code":"66605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC ","code_information":[{"code":"158","type":"RC"},{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cystography, minimum of 3 views, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"74430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":213.57,"maximum":237.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":213.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":235.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":237.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":237.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":235.59,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction ","code_information":[{"code":"329","type":"RC"},{"code":"73050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":150.19,"maximum":166.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":150.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":165.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":166.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":166.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":165.68,"methodology":"fee schedule"}]}]},{"description":"Transcatheter implantation of wireless inferior vena cava sensor for long-term hemodynamic monitoring, including deployment of the sensor, radiological supervision and interpretation, right heart cath ","code_information":[{"code":"0981T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Antibody identification; platelet associated immunoglobulin assay ","code_information":[{"code":"86023","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":20.50,"maximum":48.59,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":47.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.59,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of carpal scaphoid (navicular) fracture; without manipulation ","code_information":[{"code":"25622","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Selective enzymatic debridement, partial-thickness and/or full-thickness burn eschar, requiring anesthesia (ie, general anesthesia, moderate sedation), including patient monitoring, scalp, neck, ","code_information":[{"code":"0975T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day ","code_information":[{"code":"499","type":"RC"},{"code":"64653","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft ","code_information":[{"code":"33971","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"NEUROSES EXCEPT DEPRESSIVE  IPF","code_information":[{"code":"134","type":"RC"},{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1024.17,"maximum":1044.65,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1044.65,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1024.17,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation ","code_information":[{"code":"324","type":"RC"},{"code":"74712","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2146.57,"maximum":2384.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2146.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2367.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2384.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2384.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2367.91,"methodology":"fee schedule"}]}]},{"description":"Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight) ","code_information":[{"code":"67912","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thoracotomy, with biopsy(ies) of pleura ","code_information":[{"code":"32098","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for priapism ","code_information":[{"code":"54435","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Percutaneous treatment of mandibular fracture, with external fixation ","code_information":[{"code":"21452","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"164","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Unlisted miscellaneous pathology test ","code_information":[{"code":"89240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":213.46,"maximum":213.53,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":213.53,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":213.46,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging ","code_information":[{"code":"320","type":"RC"},{"code":"75563","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":701.35,"maximum":779.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":701.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":773.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":779.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":779.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":773.67,"methodology":"fee schedule"}]}]},{"description":"Intraventricular pacing ","code_information":[{"code":"360","type":"RC"},{"code":"93612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29614.00,"maximum":51885.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator ","code_information":[{"code":"0409T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Oncology (non-small cell lung cancer), cell-free DNA, targeted sesquence analysis of 23 gene (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpo ","code_information":[{"code":"0179U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3196.58,"maximum":7578.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3196.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7469.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3552.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3552.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":7578.52,"methodology":"fee schedule"}]}]},{"description":"Infusion, normal saline solution, sterile (500 ml = 1 unit) ","drug_information":{"unit":"500","type":"ML"},"code_information":[{"code":"17925","type":"CDM"},{"code":"J7040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.20,"maximum":3.35,"gross_charge":140.25,"discounted_cash":140.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":1.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2.42,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3.35,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3.35,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1.52,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.73,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1.38,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.73,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1.22,"methodology":"fee schedule"}]}]},{"description":"Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets, amplified probe technique, including multiplex reverse transcription for RNA ","code_information":[{"code":"0115U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":452.95,"maximum":1073.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":452.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1058.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":503.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":503.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1073.87,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"150","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Plastic repair of canaliculi ","code_information":[{"code":"490","type":"RC"},{"code":"68700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"124","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":888.67,"maximum":906.44,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":906.44,"methodology":"fee schedule","additional_payer_notes":"Days 6. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":888.67,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"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"}],"standard_charges":[{"setting":"outpatient","minimum":569.92,"maximum":1245.20,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":726.65,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1245.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":726.65,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":726.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":712.40,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":569.92,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":740.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":715.96,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":712.40,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":712.40,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":740.90,"methodology":"fee schedule"}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M ","code_information":[{"code":"150","type":"RC"},{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Special teletherapy port plan, particles, hemibody, total body ","code_information":[{"code":"323","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":235.98,"maximum":262.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":235.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":260.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":262.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":262.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":260.31,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC ","code_information":[{"code":"097","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Exploration, repair, and presacral drainage for rectal injury; ","code_information":[{"code":"45562","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Removal of indwelling tunneled pleural catheter with cuff ","code_information":[{"code":"32552","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) ","code_information":[{"code":"13102","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa ºsis») ","code_information":[{"code":"790","type":"RC"},{"code":"C9796","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"64494","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"76080","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":309.22,"maximum":343.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":309.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":341.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":343.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":343.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":341.11,"methodology":"fee schedule"}]}]},{"description":"Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous pacing lead only ","code_information":[{"code":"0920T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_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":"490","type":"RC"},{"code":"57287","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence r ","code_information":[{"code":"302","type":"RC"},{"code":"81520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4129.30,"maximum":9789.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4129.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9649.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4588.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4588.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9789.82,"methodology":"fee schedule"}]}]},{"description":"Joint survey, single view, 2 or more joints (specify) ","code_information":[{"code":"409","type":"RC"},{"code":"77077","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":82.55,"maximum":91.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":82.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":91.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":91.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":91.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":91.06,"methodology":"fee schedule"}]}]},{"description":"Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair ","code_information":[{"code":"27524","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Atomic absorption spectroscopy, each analyte ","code_information":[{"code":"309","type":"RC"},{"code":"82190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.16,"maximum":62.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.01,"methodology":"fee schedule"}]}]},{"description":"Resection, humeral head ","code_information":[{"code":"23195","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less ","code_information":[{"code":"15155","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Destruction by neurolytic agent; plantar common digital nerve ","code_information":[{"code":"481","type":"RC"},{"code":"64632","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Clotting; prekallikrein assay (Fletcher factor assay) ","code_information":[{"code":"304","type":"RC"},{"code":"85292","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.14,"maximum":73.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":72.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":73.83,"methodology":"fee schedule"}]}]},{"description":"Esophagoplasty (plastic repair or reconstruction), thoracic approach; without repair of tracheoesophageal fistula ","code_information":[{"code":"360","type":"RC"},{"code":"43310","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent ","code_information":[{"code":"304","type":"RC"},{"code":"87190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.02,"maximum":28.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.51,"methodology":"fee schedule"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"146","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1193.21,"maximum":1193.21,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1193.21,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess) ","code_information":[{"code":"25035","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Tick-borne replapsing fever Borrelia group, antibody detection to 4 recombinant protein groups, by immunoblot, IgG ","code_information":[{"code":"0044U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":24.44,"maximum":57.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":57.95,"methodology":"fee schedule"}]}]},{"description":"Inj., aristada initio, 1 m ","code_information":[{"code":"9179","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2.60,"maximum":5.67,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":3.31,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":5.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":3.31,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":3.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":3.25,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":2.60,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":3.37,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3.26,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":3.25,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":3.25,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":3.37,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, thorax, diagnostic; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"71260","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":276.58,"maximum":307.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":276.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":305.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":307.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":307.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":305.10,"methodology":"fee schedule"}]}]},{"description":"Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure ","code_information":[{"code":"481","type":"RC"},{"code":"58611","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Cervical lymphadenectomy (modified radical neck dissection) ","code_information":[{"code":"38724","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Antibody; Nocardia ","code_information":[{"code":"307","type":"RC"},{"code":"86744","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.30,"maximum":62.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.36,"methodology":"fee schedule"}]}]},{"description":"Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft ","code_information":[{"code":"27381","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study ","code_information":[{"code":"402","type":"RC"},{"code":"76828","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":247.18,"maximum":274.59,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":247.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":272.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":274.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":274.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":272.67,"methodology":"fee schedule"}]}]},{"description":"Lower extremity fascial plane block, unilateral; by continuous infusion(s), including imaging guidance, when performed ","code_information":[{"code":"64474","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed ","code_information":[{"code":"37225","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Inj., triptorelin xr 3.75 ","code_information":[{"code":"09016","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":3702.76,"maximum":3740.93,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3702.76,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3740.93,"methodology":"fee schedule"}]}]},{"description":"MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) ","code_information":[{"code":"302","type":"RC"},{"code":"81291","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":107.48,"maximum":254.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":107.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":251.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":119.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":119.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":254.83,"methodology":"fee schedule"}]}]},{"description":"MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) ","code_information":[{"code":"303","type":"RC"},{"code":"81338","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":247.29,"maximum":586.29,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":247.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":577.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":274.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":274.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":586.29,"methodology":"fee schedule"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"125","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cystectomy, complete; (separate procedure) ","code_information":[{"code":"51570","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); with fluoroscopic or CT guidance ","code_information":[{"code":"360","type":"RC"},{"code":"62329","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less ","code_information":[{"code":"11640","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, vascular surgery ","code_information":[{"code":"37799","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"VIRAL ILLNESS WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair/modification of a hearing aid ","code_information":[{"code":"V5014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":209.50,"maximum":211.66,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":209.50,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":211.66,"methodology":"fee schedule"}]}]},{"description":"Debridement of extensive eczematous or infected skin; up to 10% of body surface ","code_information":[{"code":"11000","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"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":"304","type":"RC"},{"code":"81228","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1480.50,"maximum":3510.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1480.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3459.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1645.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1645.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3510.00,"methodology":"fee schedule"}]}]},{"description":"Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial embolization, injection procedure, or balloon catheter ","code_information":[{"code":"61710","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Application of patellar tendon bearing (PTB) cast ","code_information":[{"code":"29435","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Incision of thrombosed hemorrhoid, external ","code_information":[{"code":"46083","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplast ","code_information":[{"code":"36907","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"DIABETES WITHOUT CC/MCC ","code_information":[{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":26105.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":27789.310,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":24752.460,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":27789.310,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":27789.310,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":4518.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4476.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16617.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4974.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":19385.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":4906.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4974.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":13461.40,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":7337.43,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":4906.29,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":29952.550,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":33280.620,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":4431.07,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":9152.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":10404.350,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":8320.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":10404.350,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":18724.510,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":4810.09,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":3848.07,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":11922.780,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":22044.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":11922.780,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":5002.50,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":39520.730,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":17721.930,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":11107.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4636.93,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":25501.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":4810.09,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":4810.09,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":4716.24,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":4954.39,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"092","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC ","code_information":[{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":59192.40,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":89257.650,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":79503.440,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":89257.650,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":89257.650,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":15961.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15947.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":59192.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17720.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":62266.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":17476.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17720.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47951.38,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":26136.93,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":17476.89,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":96205.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":106895.380,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":15651.61,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":29396.230,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":4923.690,"methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":26723.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":4923.690,"methodology":"percent of total billed charges","additional_payer_notes":" Between 1-10 instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":60142.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":17134.21,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":13707.37,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":38295.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":70804.830,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":38295.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":17819.58,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":126938.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":56921.790,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":35676.330,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16517.38,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":81908.590,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":17134.21,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":17134.21,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":16658.89,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":17648.24,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC ","code_information":[{"code":"982","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":15680.87,"maximum":15842.53,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":15680.87,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":15842.53,"methodology":"fee schedule"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC ","code_information":[{"code":"068","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"50695","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC* ","code_information":[{"code":"918","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3656.01,"maximum":3693.70,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3656.01,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3693.70,"methodology":"fee schedule"}]}]},{"description":"Vitamin K ","code_information":[{"code":"305","type":"RC"},{"code":"84597","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.57,"maximum":53.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.51,"methodology":"fee schedule"}]}]},{"description":"SF3B1 (splicing factor º3b» subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) ","code_information":[{"code":"306","type":"RC"},{"code":"81347","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":317.90,"maximum":753.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":742.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":753.67,"methodology":"fee schedule"}]}]},{"description":"Twelve volt battery, each ","code_information":[{"code":"L7364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":483.46,"maximum":1056.29,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":616.41,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1056.29,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":616.41,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":616.41,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":604.32,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":586.19,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":483.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":628.49,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":592.23,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":607.34,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":604.32,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":604.32,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":628.49,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) ","code_information":[{"code":"43770","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":53343.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":33726.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53343.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":37473.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":37473.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53343.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Lidocaine ","code_information":[{"code":"37084","type":"CDM"},{"code":"80176","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.75,"maximum":62.57,"gross_charge":603.75,"discounted_cash":603.75,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":13.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":14.98,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":25.68,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":62.57,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":62.55,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":14.98,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":14.98,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":47.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":54.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":43.31,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":54.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":41.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":14.69,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":14.73,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":11.75,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":15.28,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14.89,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14.76,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":14.69,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":14.69,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13.47,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":15.28,"methodology":"fee schedule"}]}]},{"description":"ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"300","type":"RC"},{"code":"81177","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"156","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multi ","code_information":[{"code":"15018","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hepatitis B surface antibody (HBsAb) ","code_information":[{"code":"305","type":"RC"},{"code":"86706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.67,"maximum":41.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":41.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":41.89,"methodology":"fee schedule"}]}]},{"description":"Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score ","code_information":[{"code":"0290U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.20,"maximum":2964.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2921.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2964.00,"methodology":"fee schedule"}]}]},{"description":"Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiolo ","code_information":[{"code":"34702","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Rare DS Whl Gen & Mitochdrl DNA Seq Alys Proband ","code_information":[{"code":"0212U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":9006.70,"maximum":21353.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9006.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21046.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10008.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10008.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21353.28,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC ","code_information":[{"code":"142","type":"RC"},{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) ","code_information":[{"code":"36823","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"329","type":"RC"},{"code":"77080","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":157.18,"maximum":174.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":157.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":173.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":174.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":174.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":173.39,"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":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"BONE DISEASES AND ARTHROPATHIES WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Lavage by cannulation; sphenoid sinus ","code_information":[{"code":"31002","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, direct, operative, with arytenoidectomy; ","code_information":[{"code":"31560","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"HLA Class II typing, high resolution (ie, alleles or allele groups); one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each ","code_information":[{"code":"81382","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":203.45,"maximum":482.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":203.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":475.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":226.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":226.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":482.35,"methodology":"fee schedule"}]}]},{"description":"Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated ","code_information":[{"code":"303","type":"RC"},{"code":"80055","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":78.65,"maximum":186.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":78.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":183.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":87.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":87.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":186.46,"methodology":"fee schedule"}]}]},{"description":"INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC ","code_information":[{"code":"351","type":"MS-DRG"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cardiovascular disease , IL-16, FAS, FASLigand, HGF, CTACK, EOTAXIN, and MCP-3 by immunoassay combined with age, sex, family history, and personal history of diabetes, blood, algorithm reported as a 5 ","code_information":[{"code":"0415U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":642.78,"maximum":1523.92,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":642.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1502.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":714.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":714.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1523.92,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, abdomen; 2 views ","code_information":[{"code":"322","type":"RC"},{"code":"74019","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":136.16,"maximum":151.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":136.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":150.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":151.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":151.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":150.20,"methodology":"fee schedule"}]}]},{"description":"Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) ","code_information":[{"code":"361","type":"RC"},{"code":"64616","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"156","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1004.28,"maximum":1004.28,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1004.28,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Valvuloplasty, mitral valve, with cardiopulmonary bypass; ","code_information":[{"code":"33425","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) ","code_information":[{"code":"369","type":"RC"},{"code":"64575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":63632.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36318.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"DIGESTIVE MALIGNANCY WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Unlisted procedure, tongue, floor of mouth ","code_information":[{"code":"41599","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair of anal fistula with fibrin glue ","code_information":[{"code":"46706","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC ","code_information":[{"code":"127","type":"RC"},{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Proctosigmoidoscopy, rigid; with removal of foreign body ","code_information":[{"code":"45307","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Pyelotomy; with exploration ","code_information":[{"code":"369","type":"RC"},{"code":"50120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Unlisted procedure, mediastinum ","code_information":[{"code":"39499","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Implantation of intrastromal corneal ring segments ","code_information":[{"code":"65785","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC ","code_information":[{"code":"098","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each ","code_information":[{"code":"A4434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":4.20,"maximum":9.18,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":5.36,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":9.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":5.36,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":5.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5.09,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":4.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":5.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5.14,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":5.28,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":5.25,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":5.46,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"686","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, maxillofacial area; without contrast material ","code_information":[{"code":"321","type":"RC"},{"code":"70486","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":203.96,"maximum":226.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":203.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":224.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":226.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":226.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":224.99,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure) ","code_information":[{"code":"25830","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Drainage of perineal urinary extravasation; complicated ","code_information":[{"code":"490","type":"RC"},{"code":"53085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Removal of fecal impaction or foreign body (separate procedure) under anesthesia ","code_information":[{"code":"369","type":"RC"},{"code":"45915","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic a3cid, genitourinary pathogen, semiquantitative identification, DNA from 16 bacterial organisms and 1 fungal organism, multiplex amplified probe technique via qua ","code_information":[{"code":"0371U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age ","code_information":[{"code":"33985","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MAJOR HEAD AND NECK PROCEDURES WITH MCC ","code_information":[{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":114096.77,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":223038.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":198664.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":223038.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":223038.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":30498.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30740.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":114096.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34156.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":155592.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":33687.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34156.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":92429.05,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":50380.44,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":33687.72,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":240401.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":267112.430,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":29905.87,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":73455.920,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":83506.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":66778.110,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":83506.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":150284.130,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":33027.18,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":26421.74,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":95693.030,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":176928.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":95693.030,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":34348.27,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":317196.010,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":142237.370,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":89148.770,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":31838.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":204674.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":33027.18,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":33027.18,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":31830.50,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":34018.00,"methodology":"fee schedule"}]}]},{"description":"Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), initial artery, open or percutaneous, including all ","code_information":[{"code":"499","type":"RC"},{"code":"C7532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closure of single ventricular septal defect, with or without patch; ","code_information":[{"code":"33681","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC ","code_information":[{"code":"204","type":"RC"},{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH MCC ","code_information":[{"code":"196","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thyroxine; free ","code_information":[{"code":"304","type":"RC"},{"code":"84439","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.84,"maximum":35.18,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":34.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35.18,"methodology":"fee schedule"}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT ","code_information":[{"code":"158","type":"RC"},{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Vaginal hysterectomy, for uterus 250 g or less; ","code_information":[{"code":"490","type":"RC"},{"code":"58260","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Hematology (inherited thrombocytopenia), geonomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0276U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1958.85,"maximum":10427.90,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2497.53,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":4279.84,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":10427.90,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10424.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2497.53,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2497.53,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":7147.10,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":8121.63,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":6497.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":8121.63,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":6225.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":2448.56,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1958.85,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2546.50,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2460.80,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":2448.56,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":2448.56,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":2546.50,"methodology":"fee schedule"}]}]},{"description":"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION  IPF","code_information":[{"code":"116","type":"RC"},{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1288.66,"maximum":1288.66,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1288.66,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis ","code_information":[{"code":"81191","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":341.02,"maximum":808.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":341.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":796.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":808.51,"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":"402","type":"RC"},{"code":"76506","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":567.66,"maximum":630.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":567.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":626.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":630.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":630.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":626.19,"methodology":"fee schedule"}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC ","code_information":[{"code":"130","type":"RC"},{"code":"287","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"External counterpulsation, per treatment session ","code_information":[{"code":"750","type":"RC"},{"code":"G0166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft ","code_information":[{"code":"481","type":"RC"},{"code":"61606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"COMPLICATIONS OF TREATMENT WITH MCC ","code_information":[{"code":"128","type":"RC"},{"code":"919","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"27328","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Proctopexy (eg, for prolapse); perineal approach ","code_information":[{"code":"45541","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Gingivoplasty, each quadrant (specify) ","code_information":[{"code":"361","type":"RC"},{"code":"41872","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Syphilis test, non-treponemal antibody, immunoassay, qualitative (RPR) ","code_information":[{"code":"0065U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29.76,"maximum":70.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":69.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.55,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; respiratory syncytial virus ","code_information":[{"code":"309","type":"RC"},{"code":"87280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.08,"maximum":52.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.34,"methodology":"fee schedule"}]}]},{"description":"Insertion of penile prosthesis; non-inflatable (semi-rigid) ","code_information":[{"code":"369","type":"RC"},{"code":"54400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":26605.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubis ","code_information":[{"code":"27075","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"DIGESTIVE MALIGNANCY WITH CC ","code_information":[{"code":"123","type":"RC"},{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Quinine ","code_information":[{"code":"84228","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.30,"maximum":49.53,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":11.86,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":20.33,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":49.53,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":49.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":11.86,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":11.86,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":37.74,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":42.89,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":34.31,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":42.89,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":32.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":11.63,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":11.67,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9.30,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12.10,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":11.79,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11.69,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11.63,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":11.63,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":10.66,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12.10,"methodology":"fee schedule"}]}]},{"description":"Destruction by neurolytic agent; plantar common digital nerve ","code_information":[{"code":"64632","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Replacement pad for use with medically necessary alternating pressure pad owned by patient ","code_information":[{"code":"A4640","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":56.45,"maximum":123.33,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":71.97,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":123.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":71.97,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":71.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":70.56,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":68.44,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":56.45,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":73.38,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":69.15,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":70.91,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":70.56,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":70.56,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":73.38,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair ","code_information":[{"code":"360","type":"RC"},{"code":"40810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Reconstruction of mandible or maxilla, subperiosteal implant; complete ","code_information":[{"code":"21246","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"70552","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":1002.04,"maximum":1113.16,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1002.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1105.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1113.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1113.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1105.37,"methodology":"fee schedule"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"110","type":"RC"},{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"210","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil ","code_information":[{"code":"0978T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, mastoids; less than 3 views per side ","code_information":[{"code":"409","type":"RC"},{"code":"70120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":199.23,"maximum":221.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":199.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":219.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":221.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":221.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":219.77,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF NERVOUS SYSTEM WITH CC ","code_information":[{"code":"092","type":"MS-DRG"},{"code":"155","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Unlisted fluoroscopic procedure (eg, diagnostic, interventional) ","code_information":[{"code":"76496","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":405.00,"maximum":405.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":405.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":405.00,"methodology":"fee schedule"}]}]},{"description":"Stump elongation, upper extremity ","code_information":[{"code":"24935","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION  IPF","code_information":[{"code":"134","type":"RC"},{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1137.06,"maximum":1159.80,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1159.80,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1137.06,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) ","code_information":[{"code":"499","type":"RC"},{"code":"50389","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"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":"490","type":"RC"},{"code":"64569","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Ciliary body destruction; cryotherapy ","code_information":[{"code":"66720","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum ","code_information":[{"code":"29862","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia ","code_information":[{"code":"360","type":"RC"},{"code":"54316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length ","code_information":[{"code":"64898","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect ","code_information":[{"code":"304","type":"RC"},{"code":"87252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.89,"maximum":101.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":42.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":100.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":47.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":47.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":101.67,"methodology":"fee schedule"}]}]},{"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":"341","type":"RC"},{"code":"73432","type":"CDM"},{"code":"78451","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":1274.77,"maximum":1416.14,"gross_charge":10857.00,"discounted_cash":10857.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1274.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1406.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1416.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1416.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1406.22,"methodology":"fee schedule"}]}]},{"description":"Repair lip, full thickness; vermilion only ","code_information":[{"code":"40650","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Atomic absorption spectroscopy, each analyte ","code_information":[{"code":"302","type":"RC"},{"code":"82190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.16,"maximum":62.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.01,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac, mediastinal or pleural space, without biopsy ","code_information":[{"code":"32601","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Chloride; blood ","code_information":[{"code":"300","type":"RC"},{"code":"82435","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.57,"maximum":17.94,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17.94,"methodology":"fee schedule"}]}]},{"description":"Clotting; factor IX (PTC or Christmas) ","code_information":[{"code":"307","type":"RC"},{"code":"85250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.32,"maximum":74.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":73.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":74.26,"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":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1221.03,"maximum":2894.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1221.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2853.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1356.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1356.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2894.85,"methodology":"fee schedule"}]}]},{"description":"Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster ","code_information":[{"code":"Q4013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":15.74,"maximum":34.40,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":20.07,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":34.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":20.07,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":20.07,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":19.68,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":19.09,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":15.74,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":20.47,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":19.29,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19.78,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":19.68,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":19.68,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":20.47,"methodology":"fee schedule"}]}]},{"description":" Occupational Therapy Other  ","code_information":[{"code":"439","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":153.00,"maximum":324.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":153.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":324.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":170.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":170.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":324.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_percentage":38.20,"standard_charge_algorithm":"Reimbursement will be 38.2% of billable gross charges.","estimated_amount":189.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":200.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_percentage":44.10,"standard_charge_algorithm":"Reimbursement will be 44.1% of billable gross charges.","estimated_amount":218.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":250.00,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":206.27,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":234.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":187.52,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":234.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":179.66,"methodology":"fee schedule"},{"payer_name":"MVP Health Plan","plan_name":"COMM","standard_charge_dollar":175.00,"methodology":"case rate"}]}]},{"description":"Bypass graft, with vein; subclavian-vertebral ","code_information":[{"code":"35515","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"APPENDIX PROCEDURES WITH CC ","code_information":[{"code":"361","type":"RC"},{"code":"398","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Blood count; reticulocyte, manual ","code_information":[{"code":"300","type":"RC"},{"code":"85044","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.09,"maximum":16.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.81,"methodology":"fee schedule"}]}]},{"description":"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC ","code_information":[{"code":"499","type":"RC"},{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER FACTORS INFLUENCING HEALTH STATUS ","code_information":[{"code":"208","type":"RC"},{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"167","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Posaconazole ","code_information":[{"code":"302","type":"RC"},{"code":"80187","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.60,"maximum":105.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":104.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":49.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":49.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":105.73,"methodology":"fee schedule"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC ","code_information":[{"code":"094","type":"MS-DRG"},{"code":"150","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy ","code_information":[{"code":"19370","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or ","code_information":[{"code":"481","type":"RC"},{"code":"61626","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Oncology (solid organ), target geonomic sequence analysis, FFPE tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, ","code_information":[{"code":"0334U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4802.74,"maximum":11386.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4802.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":11222.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5337.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5337.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":11386.44,"methodology":"fee schedule"}]}]},{"description":"Nerve pedicle transfer; first stage ","code_information":[{"code":"64905","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"323","type":"RC"},{"code":"77078","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":522.58,"maximum":580.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":522.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":576.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":580.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":580.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":576.47,"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Suture pharynx for wound or injury ","code_information":[{"code":"42900","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Excimer laser treatment for psoriasis; total area less than 250 sq cm ","code_information":[{"code":"790","type":"RC"},{"code":"96920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach ","code_information":[{"code":"360","type":"RC"},{"code":"63305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including labyrinthectomy, decompression, with or without mobilization of facial nerve and/or petrous carotid ","code_information":[{"code":"361","type":"RC"},{"code":"61596","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Inj recombin esperoct per ","code_information":[{"code":"9354","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.78,"maximum":3.89,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2.27,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":3.89,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2.27,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2.27,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":2.22,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1.78,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2.31,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2.23,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":2.22,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":2.22,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":2.31,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique ","code_information":[{"code":"306","type":"RC"},{"code":"87591","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, rectum ","code_information":[{"code":"45499","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant ","code_information":[{"code":"302","type":"RC"},{"code":"81240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":108.06,"maximum":256.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":108.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":252.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":120.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":120.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":256.19,"methodology":"fee schedule"}]}]},{"description":"Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands ","code_information":[{"code":"42509","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision ","code_information":[{"code":"312","type":"RC"},{"code":"88147","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":83.17,"maximum":197.18,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":83.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":194.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":92.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":92.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":197.18,"methodology":"fee schedule"}]}]},{"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":"49614","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":14872.70,"methodology":"case rate"}]}]},{"description":"Arthroscopy, shoulder, surgical; with removal of loose body or foreign body ","code_information":[{"code":"29819","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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 arterial ","code_information":[{"code":"37244","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"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":756.47,"maximum":1793.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":756.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1767.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":840.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":840.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1793.45,"methodology":"fee schedule"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar ","code_information":[{"code":"361","type":"RC"},{"code":"63030","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"499","type":"RC"},{"code":"743","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of foreign body, shoulder; subcutaneous ","code_information":[{"code":"23330","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated ","code_information":[{"code":"L2126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1294.20,"maximum":2827.67,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1650.11,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2827.67,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1650.11,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1650.11,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1617.75,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1569.22,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1294.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1682.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1585.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1625.84,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1617.75,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1617.75,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1682.46,"methodology":"fee schedule"}]}]},{"description":"Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues ","code_information":[{"code":"11010","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"IDH1 (isocitrate dehydrogenase 1 ºNADP+», soluble) (eg, glioma), common variants (eg, R132H, R132C) ","code_information":[{"code":"309","type":"RC"},{"code":"81120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":317.90,"maximum":753.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":742.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":753.67,"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon ","code_information":[{"code":"360","type":"RC"},{"code":"61623","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Borrelia burgdoferi, antibody detection of 12 recombinant protein groups, by immunoblot, IgG ","code_information":[{"code":"0042U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28.31,"maximum":67.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67.12,"methodology":"fee schedule"}]}]},{"description":"CYSTOURETHROSCOPY, WITH MECHANICAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY FOR URETHRAL STRICTURE OR STENOSIS, INCLUDING FLUOROSCOPY, WHEN PERFORMED ","code_information":[{"code":"0499T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Liver and spleen imaging; with vascular flow ","code_information":[{"code":"342","type":"RC"},{"code":"78216","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":705.67,"maximum":783.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":705.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":778.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":783.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":783.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":778.43,"methodology":"fee schedule"}]}]},{"description":"VENTRICULAR SHUNT PROCEDURES WITH CC ","code_information":[{"code":"032","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"211","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck ","code_information":[{"code":"481","type":"RC"},{"code":"51715","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein ","code_information":[{"code":"44715","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular territory (List separately in addition to code for primary procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"61641","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, ankle; 2 views ","code_information":[{"code":"323","type":"RC"},{"code":"73600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":166.12,"maximum":184.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":166.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":183.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":184.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":184.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":183.25,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITH CC ","code_information":[{"code":"110","type":"RC"},{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tenodesis of biceps tendon at elbow (separate procedure) ","code_information":[{"code":"24340","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Atrial septectomy or septostomy; open heart with cardiopulmonary bypass ","code_information":[{"code":"33736","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ENDOCRINE DISORDERS WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Anoplasty, plastic operation for stricture; adult ","code_information":[{"code":"46700","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique ","code_information":[{"code":"300","type":"RC"},{"code":"87531","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":95.41,"maximum":226.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":95.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":222.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":106.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":106.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":226.20,"methodology":"fee schedule"}]}]},{"description":"Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) ","code_information":[{"code":"309","type":"RC"},{"code":"83701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.70,"maximum":132.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":130.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":61.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":61.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":132.05,"methodology":"fee schedule"}]}]},{"description":"Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array an ","code_information":[{"code":"81405","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":495.72,"maximum":1175.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":495.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1158.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":550.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":550.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1175.27,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, wrist, surgical; synovectomy, complete ","code_information":[{"code":"29845","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG ºany form»), utilizing maternal serum, algorithm reported as a risk score ","code_information":[{"code":"303","type":"RC"},{"code":"81510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":91.36,"maximum":216.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":91.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":213.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":101.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":101.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":216.61,"methodology":"fee schedule"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer ","code_information":[{"code":"361","type":"RC"},{"code":"38215","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Unlisted fetal invasive procedure, including ultrasound guidance, when performed ","code_information":[{"code":"59897","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closed treatment of hip dislocation, traumatic; without anesthesia ","code_information":[{"code":"27250","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial ","code_information":[{"code":"29895","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) ","code_information":[{"code":"21385","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, abdomen; 2 views ","code_information":[{"code":"323","type":"RC"},{"code":"74019","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":136.16,"maximum":151.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":136.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":150.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":151.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":151.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":150.20,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy; with biopsy(ies) of pleura ","code_information":[{"code":"32609","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion ","code_information":[{"code":"11055","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna ","code_information":[{"code":"25375","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); qualitative ","code_information":[{"code":"304","type":"RC"},{"code":"82009","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.44,"maximum":17.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17.63,"methodology":"fee schedule"}]}]},{"description":"Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each ","code_information":[{"code":"28455","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tissue culture for non-neoplastic disorders; skin or other solid tissue biopsy ","code_information":[{"code":"319","type":"RC"},{"code":"88233","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":231.50,"maximum":548.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":231.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":540.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":257.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":257.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":548.85,"methodology":"fee schedule"}]}]},{"description":"Complex dynamic pharyngeal and speech evaluation by cine or video recording ","code_information":[{"code":"70371","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":262.03,"maximum":1088.58,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1088.58,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1088.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":288.23,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":327.54,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":262.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":327.54,"methodology":"fee schedule"}]}]},{"description":"Dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection ","code_information":[{"code":"303","type":"RC"},{"code":"87164","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.67,"maximum":41.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":41.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":41.89,"methodology":"fee schedule"}]}]},{"description":"Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) ","code_information":[{"code":"490","type":"RC"},{"code":"67924","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infusion or instillation of radioelement solution (includes 3-month follow-up care) ","code_information":[{"code":"323","type":"RC"},{"code":"77750","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2050.55,"maximum":2277.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2050.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2261.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2277.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2277.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2261.99,"methodology":"fee schedule"}]}]},{"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":"81462","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1967.14,"maximum":4663.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1967.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4596.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2185.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2185.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4663.74,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"118","type":"RC"},{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Culture, fungi, definitive identification, each organism; mold ","code_information":[{"code":"87107","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":16.98,"maximum":40.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40.25,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), ea ","code_information":[{"code":"31651","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation ","code_information":[{"code":"20808","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"MAJOR BLADDER PROCEDURES WITH MCC ","code_information":[{"code":"360","type":"RC"},{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED ","code_information":[{"code":"361","type":"RC"},{"code":"49587","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) ","code_information":[{"code":"322","type":"RC"},{"code":"72147","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1433.91,"maximum":1592.92,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1433.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1581.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1592.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1592.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1581.76,"methodology":"fee schedule"}]}]},{"description":"Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); with optic nerve decompression ","code_information":[{"code":"369","type":"RC"},{"code":"61564","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Penile venous occlusive procedure ","code_information":[{"code":"37790","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC ","code_information":[{"code":"178","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HEADACHES WITH MCC ","code_information":[{"code":"102","type":"MS-DRG"},{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of posterior malleolus fracture; without manipulation ","code_information":[{"code":"27767","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"177","type":"MS-DRG"},{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each ","code_information":[{"code":"37239","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"270","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral ","code_information":[{"code":"31574","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial ","code_information":[{"code":"J3240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2016.35,"maximum":5546.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2695.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3098.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2995.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":2462.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2995.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3697.85,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5546.13,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5546.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":2357.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":2678.99,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":2143.19,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":2678.99,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2016.35,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2037.14,"methodology":"fee schedule"}]}]},{"description":"Open treatment of fracture of orbit, except blowout; with implant ","code_information":[{"code":"21407","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Pneumonostomy, with open drainage of abscess or cyst ","code_information":[{"code":"32200","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"209","type":"RC"},{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"130","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection of medication or other substance into Tenon's capsule ","code_information":[{"code":"360","type":"RC"},{"code":"67515","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Urethrorrhaphy, suture of urethral wound or injury; penile ","code_information":[{"code":"490","type":"RC"},{"code":"53505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE PREGNANCY REQUIRING TOTAL HYSTERECTOMY ","code_information":[{"code":"59135","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ureteroneocystostomy; with vesico-psoas hitch or bladder flap ","code_information":[{"code":"50785","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repositioning of previously implanted cardiac contractility modulation-defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sensing and therapeutic param ","code_information":[{"code":"0924T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Semen analysis; presence and/or motility of sperm including Huhner test (post coital) ","code_information":[{"code":"305","type":"RC"},{"code":"89300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.19,"maximum":38.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":38.38,"methodology":"fee schedule"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical) ","code_information":[{"code":"32650","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC ","code_information":[{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":91982.55,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":252802.130,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":225175.550,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":252802.130,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":252802.130,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24781.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":91982.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27536.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":176355.980,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":27158.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27536.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":74514.46,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":40615.71,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":27158.38,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":272481.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":302757.040,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":83258.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":94649.420,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":75689.260,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":94649.420,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":170338.680,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":26625.86,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":21300.69,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":108462.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":200538.690,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":108462.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":27690.89,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":359523.980,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":161218.120,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":101045.160,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25667.33,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":231987.580,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":26625.86,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":26625.86,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":27424.64,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance ","code_information":[{"code":"43236","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC ","code_information":[{"code":"519","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14701.23,"maximum":14852.79,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":14701.23,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14852.79,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable moni ","code_information":[{"code":"0527T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary procedure) ","code_information":[{"code":"33768","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"58660","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis ","code_information":[{"code":"43337","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"164","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Inj risankizumab-rzaa 1 mg ","code_information":[{"code":"09013","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":14.49,"maximum":14.64,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":14.49,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14.64,"methodology":"fee schedule"}]}]},{"description":"PNEUMOTHORAX WITH CC ","code_information":[{"code":"155","type":"RC"},{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision of synovial cyst of popliteal space (eg, Baker's cyst) ","code_information":[{"code":"27345","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, chest; 2 views ","code_information":[{"code":"409","type":"RC"},{"code":"71046","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":52.27,"maximum":58.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":52.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":58.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":58.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":57.66,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  IPF","code_information":[{"code":"146","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":994.34,"maximum":994.34,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":994.34,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"Level 2 Airway Endoscopy ","code_information":[{"code":"05152","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":410.22,"maximum":414.45,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":410.22,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":414.45,"methodology":"fee schedule"}]}]},{"description":"Artacent ac, per square centimeter ","code_information":[{"code":"Q4190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":172.17,"maximum":632.12,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":632.12,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":632.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":286.67,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":325.72,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":260.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":325.72,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":172.17,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":173.94,"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; duplication/deletion variants ","code_information":[{"code":"301","type":"RC"},{"code":"81269","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":332.95,"maximum":789.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":332.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":778.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":369.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":369.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":789.36,"methodology":"fee schedule"}]}]},{"description":"Construction of artificial vagina; without graft ","code_information":[{"code":"57291","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Volume reduction of blood or blood product (eg, red blood cells or platelets), each unit ","code_information":[{"code":"300","type":"RC"},{"code":"86960","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Antibody; influenza virus ","code_information":[{"code":"304","type":"RC"},{"code":"86710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.29,"maximum":52.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.84,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone ","code_information":[{"code":"26607","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"318","type":"MS-DRG"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Free fascial flap with microvascular anastomosis ","code_information":[{"code":"15758","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Suture of quadriceps or hamstring muscle rupture; primary ","code_information":[{"code":"27385","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure) ","code_information":[{"code":"14302","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) ","code_information":[{"code":"33211","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":14872.70,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique ","code_information":[{"code":"306","type":"RC"},{"code":"38587","type":"CDM"},{"code":"87556","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":68.56,"maximum":162.55,"gross_charge":878.75,"discounted_cash":878.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":68.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":160.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":76.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":76.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":162.55,"methodology":"fee schedule"}]}]},{"description":"Fat stain, feces, urine, or respiratory secretions ","code_information":[{"code":"306","type":"RC"},{"code":"89125","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.67,"maximum":22.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22.93,"methodology":"fee schedule"}]}]},{"description":"Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the ","code_information":[{"code":"37249","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, ","code_information":[{"code":"B4154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.78,"maximum":1.20,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1.06,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.20,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.78,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.78,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES ","code_information":[{"code":"134","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":8327.00,"maximum":8327.00,"payers_information":[{"payer_name":"Granite State Health","plan_name":"MGMCDBH","standard_charge_dollar":8327.00,"methodology":"case rate"}]}]},{"description":"HLA typing; lymphocyte culture, mixed (MLC) ","code_information":[{"code":"301","type":"RC"},{"code":"86821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":60.14,"maximum":142.58,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":60.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":140.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":66.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":66.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":142.58,"methodology":"fee schedule"}]}]},{"description":"New Technology - Level 32 ","code_information":[{"code":"01569","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":7659.62,"maximum":7738.59,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":7659.62,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":7738.59,"methodology":"fee schedule"}]}]},{"description":"Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific pat ","code_information":[{"code":"L1820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":137.19,"maximum":299.75,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":174.92,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":299.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":174.92,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":174.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":171.49,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":166.35,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":137.19,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":178.35,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":168.06,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":172.35,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":171.49,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":171.49,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":178.35,"methodology":"fee schedule"}]}]},{"description":"Banding of pulmonary artery ","code_information":[{"code":"33690","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Repair blood vessel with vein graft; lower extremity ","code_information":[{"code":"35256","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach ","code_information":[{"code":"58145","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Sphincteroplasty, anal, for incontinence or prolapse; child ","code_information":[{"code":"46751","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) ","code_information":[{"code":"31631","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indir ","code_information":[{"code":"481","type":"RC"},{"code":"62287","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Chemodenervation of extraocular muscle ","code_information":[{"code":"67345","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":26950.63,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":77549.210,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":69074.520,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":77549.210,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":77549.210,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7107.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7261.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26950.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8068.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":54098.700,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":7957.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8068.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21832.53,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":11900.29,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":7957.33,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":83585.970,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":92873.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":6969.08,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":25540.160,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":29034.520,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":23218.330,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":29034.520,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":52252.840,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":7801.30,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":6241.04,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":33271.860,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":61516.950,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":33271.860,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":8113.35,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":110287.050,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":49455.030,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":30996.470,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7520.45,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":71164.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":7801.30,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":7801.30,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":7417.59,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":8035.34,"methodology":"fee schedule"}]}]},{"description":"Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"77012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":647.18,"maximum":718.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":647.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":713.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":718.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":718.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":713.91,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps ","code_information":[{"code":"45333","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Management of liver hemorrhage; simple suture of liver wound or injury ","code_information":[{"code":"47350","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"PROSTATECTOMY WITH MCC ","code_information":[{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":83492.10,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":120472.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":107307.010,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":120472.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":120472.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":24760.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22494.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83492.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24994.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":84042.130,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":24651.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24994.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67636.40,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":36866.68,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":24651.52,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":129850.500,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":144278.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":24279.68,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":39676.540,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":45105.010,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":36069.580,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":45105.010,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":81174.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":24168.16,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":19334.53,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":51687.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":95566.360,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":51687.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":25134.89,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":171330.520,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":76828.210,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":48152.890,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":23298.11,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":110553.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":24168.16,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":24168.16,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":25842.24,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":24893.20,"methodology":"fee schedule"}]}]},{"description":"Porphyrins, feces, quantitative ","code_information":[{"code":"84126","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":64.34,"maximum":152.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":64.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":150.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":71.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":71.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":152.53,"methodology":"fee schedule"}]}]},{"description":"CHOLECYSTECTOMY WITH C.D.E. WITH MCC ","code_information":[{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":88363.28,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":211306.100,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":188214.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":211306.100,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":211306.100,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":19733.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23806.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":88363.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26452.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":147408.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":26089.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26452.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":71582.51,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":39017.59,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":26089.76,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":227755.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":253061.200,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":19350.77,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":69591.830,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":79113.260,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":63265.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":79113.260,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":142378.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":25578.20,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":20462.56,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":90659.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":167621.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":90659.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":26601.33,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":300510.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":134755.090,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":84459.180,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":24657.38,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":193908.140,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":25578.20,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":25578.20,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":20596.12,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":26345.55,"methodology":"fee schedule"}]}]},{"description":"Osmolality; urine ","code_information":[{"code":"301","type":"RC"},{"code":"37993","type":"CDM"},{"code":"83935","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.22,"maximum":26.60,"gross_charge":316.75,"discounted_cash":316.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":26.60,"methodology":"fee schedule"}]}]},{"description":"Repair recurrent inguinal hernia, any age; reducible ","code_information":[{"code":"49520","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Closed treatment of sternoclavicular dislocation; without manipulation ","code_information":[{"code":"23520","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALL ","code_information":[{"code":"447","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"164","type":"RC"},{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon ","code_information":[{"code":"27680","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Urethromeatoplasty, with mucosal advancement ","code_information":[{"code":"369","type":"RC"},{"code":"53450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"MAJOR HEAD AND NECK PROCEDURES WITH MCC ","code_information":[{"code":"140","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cross-over vein graft to venous system ","code_information":[{"code":"34520","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE ","code_information":[{"code":"369","type":"RC"},{"code":"49585","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Manipulation, finger joint, under anesthesia, each joint ","code_information":[{"code":"26340","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC ","code_information":[{"code":"717","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":50570.88,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":109676.750,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":97691.120,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":109676.750,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":109676.750,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":13380.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13624.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50570.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":15139.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":76511.030,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":14931.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":15139.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40967.14,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":22330.02,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":14931.34,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":118214.460,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":131349.400,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":13120.68,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":36121.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":41063.110,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":32837.350,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":41063.110,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":73900.460,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":14638.57,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":11710.86,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":47055.920,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":87002.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":47055.920,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":15224.11,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":155977.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":69943.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":43837.860,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14111.58,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":100646.480,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":14638.57,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":14638.57,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13965.08,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":15077.73,"methodology":"fee schedule"}]}]},{"description":"Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and ","code_information":[{"code":"306","type":"RC"},{"code":"81301","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":573.38,"maximum":1359.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":573.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1339.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":637.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":637.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1359.38,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) ","code_information":[{"code":"29885","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus ","code_information":[{"code":"361","type":"RC"},{"code":"61598","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"321","type":"RC"},{"code":"73723","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2021.36,"maximum":2245.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2021.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2229.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2245.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2245.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2229.78,"methodology":"fee schedule"}]}]},{"description":"SEPTIC ARTHRITIS WITH MCC ","code_information":[{"code":"118","type":"RC"},{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"154","type":"RC"},{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour ","code_information":[{"code":"49133","type":"CDM"},{"code":"92605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":85.86,"maximum":86.75,"gross_charge":758.25,"discounted_cash":758.25,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":85.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":86.75,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) ","code_information":[{"code":"29860","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each ","code_information":[{"code":"26740","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Closed treatment of proximal tibiofibular joint dislocation; without anesthesia ","code_information":[{"code":"27830","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) ","code_information":[{"code":"481","type":"RC"},{"code":"67906","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Burr hole(s) or trephine; with drainage of brain abscess or cyst ","code_information":[{"code":"369","type":"RC"},{"code":"61150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions ","code_information":[{"code":"322","type":"RC"},{"code":"74178","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":1304.89,"maximum":1449.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1304.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1439.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1449.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1449.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1439.44,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps ","code_information":[{"code":"360","type":"RC"},{"code":"45384","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Arthroplasty, patella; without prosthesis ","code_information":[{"code":"27437","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":5292.280,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":6016.360,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":6016.360,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Lactate (lactic acid) ","code_information":[{"code":"300","type":"RC"},{"code":"83605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.03,"maximum":45.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45.12,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"321","type":"RC"},{"code":"72191","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":1178.86,"maximum":1309.59,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1178.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1300.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1309.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1309.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1300.41,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the ","code_information":[{"code":"37235","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Leukocyte phagocytosis ","code_information":[{"code":"300","type":"RC"},{"code":"86344","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.09,"maximum":40.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40.52,"methodology":"fee schedule"}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker) ","code_information":[{"code":"499","type":"RC"},{"code":"67041","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"RENAL FAILURE WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"320","type":"RC"},{"code":"74250","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":192.03,"maximum":213.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":192.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":211.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":213.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":213.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":211.83,"methodology":"fee schedule"}]}]},{"description":"MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":34690.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":115934.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":103265.450,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":115934.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":115934.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8979.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8548.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":31730.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9499.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":80876.810,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9368.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9499.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":25704.95,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":14011.04,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9368.72,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":124959.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":138844.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":8805.57,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":38182.180,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":43406.200,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":34711.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":43406.200,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":78117.280,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":9185.01,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":7348.01,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":49740.970,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":91967.000,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":49740.970,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9552.42,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":164877.610,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":73934.590,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":46339.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8854.35,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":106389.450,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":9185.01,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":9185.01,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":9372.27,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":9460.57,"methodology":"fee schedule"}]}]},{"description":"Autoimmune diseases (eg, systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorbent immunoassay (ELISA), fl ","code_information":[{"code":"0312U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1382.87,"maximum":3278.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1382.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3231.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1536.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1536.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3278.53,"methodology":"fee schedule"}]}]},{"description":"CERVICAL SPINAL FUSION WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Autoimmune diseases (eg, systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorbent immunoassay (ELISA), fl ","code_information":[{"code":"0312U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1382.87,"maximum":3278.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1382.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3231.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1536.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1536.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3278.53,"methodology":"fee schedule"}]}]},{"description":"Wet mounts, including preparations of vaginal, cervical or skin specimens ","code_information":[{"code":"301","type":"RC"},{"code":"Q0111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":24.92,"maximum":59.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":58.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":59.09,"methodology":"fee schedule"}]}]},{"description":"Pyruvate ","code_information":[{"code":"307","type":"RC"},{"code":"84210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.82,"maximum":56.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.47,"methodology":"fee schedule"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"144","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) ","code_information":[{"code":"306","type":"RC"},{"code":"81274","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":452.10,"maximum":1071.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":452.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1056.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1071.84,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus ","code_information":[{"code":"31636","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Inj, bortezomib, dr. reddy ","code_information":[{"code":"09026","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":4.76,"maximum":4.81,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":4.76,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":4.81,"methodology":"fee schedule"}]}]},{"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"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":"481","type":"RC"},{"code":"64569","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm ","code_information":[{"code":"12042","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH CC ","code_information":[{"code":"145","type":"RC"},{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Glucose, body fluid, other than blood ","code_information":[{"code":"304","type":"RC"},{"code":"82945","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.46,"maximum":15.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":15.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15.33,"methodology":"fee schedule"}]}]},{"description":"Antibody to human leukocyte antigens (HLA), solid phase assays (eg, microspheres or beads, ELISA, flow cytometry); qualitative assessment of the presence or absence of antibody(ies) to HLA Class I and ","code_information":[{"code":"305","type":"RC"},{"code":"86828","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":105.59,"maximum":250.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":105.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":246.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":117.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":117.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":250.34,"methodology":"fee schedule"}]}]},{"description":"ATHEROSCLEROSIS WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Aortic suspension (aortopexy) for tracheal decompression (eg, for tracheomalacia) (separate procedure) ","code_information":[{"code":"33800","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when performed ","code_information":[{"code":"46262","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diap ","code_information":[{"code":"369","type":"RC"},{"code":"58960","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"360","type":"RC"},{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation ","code_information":[{"code":"21330","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Testosterone; free ","code_information":[{"code":"306","type":"RC"},{"code":"84402","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.90,"maximum":99.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":41.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":97.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":46.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":46.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":99.33,"methodology":"fee schedule"}]}]},{"description":"Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when ","code_information":[{"code":"33745","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY  IPF","code_information":[{"code":"146","type":"RC"},{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1653.79,"maximum":1653.79,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1653.79,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":26105.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":112486.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":100193.540,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":112486.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":112486.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":6608.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6381.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":23687.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7091.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":78470.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":6993.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7091.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19188.78,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":10459.26,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":6993.76,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":121242.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":134714.000,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":6479.73,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":37046.350,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":42114.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":33678.500,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":42114.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":75793.460,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":6856.63,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":5485.30,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":48261.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":89231.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":48261.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":7130.89,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":159972.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":71735.210,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":44960.800,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6609.79,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":103224.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":6856.63,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":6856.63,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":6896.74,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":7062.33,"methodology":"fee schedule"}]}]},{"description":"SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analys ","code_information":[{"code":"81329","type":"CPT"},{"code":"85506","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":109.60,"maximum":583.46,"gross_charge":1733.75,"discounted_cash":1733.75,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":122.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":139.74,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":239.46,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":583.46,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":583.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":139.74,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":139.74,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":399.89,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":454.42,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":363.54,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":454.42,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":348.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":109.60,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":142.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":137.68,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":125.62,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":142.48,"methodology":"fee schedule"}]}]},{"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":972.96,"maximum":972.96,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":972.96,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Level 2 Extraocular, Repai ","code_information":[{"code":"5502","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":843.87,"maximum":1843.75,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1075.93,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1843.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1075.93,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1075.93,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1054.84,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":843.87,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1097.03,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1060.11,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1054.84,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1054.84,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1097.03,"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":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":131.33,"maximum":145.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":131.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":144.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":145.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":145.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":144.87,"methodology":"fee schedule"}]}]},{"description":"Aortography, thoracic, without serialography, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"75600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":903.71,"maximum":1003.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":903.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":996.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1003.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1003.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":996.90,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 ","code_information":[{"code":"22551","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12033.90,"maximum":35000.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26550.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Gastrin ","code_information":[{"code":"302","type":"RC"},{"code":"82941","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.00,"maximum":68.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":67.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":68.76,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"150","type":"RC"},{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Red cell antigen (Yt blood group) genotyping (YT), gene analysis, ACHE (acetylcholinesterase (Cartwright blood group)) exon 2 ","code_information":[{"code":"0201U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC ","code_information":[{"code":"149","type":"RC"},{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus ","code_information":[{"code":"21340","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material ","code_information":[{"code":"321","type":"RC"},{"code":"72141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1000.96,"maximum":1111.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1000.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1104.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1111.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1111.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1104.18,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, conjunctiva ","code_information":[{"code":"490","type":"RC"},{"code":"68399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC ","code_information":[{"code":"124","type":"RC"},{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"126","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Volume measurement for timed collection, each ","code_information":[{"code":"305","type":"RC"},{"code":"81050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.99,"maximum":14.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":13.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14.20,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; with salpingostomy (salpingoneostomy) ","code_information":[{"code":"481","type":"RC"},{"code":"58673","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"202","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Insertion of sinus tarsi implant ","code_information":[{"code":"0335T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at lea ","code_information":[{"code":"309","type":"RC"},{"code":"81439","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":962.16,"maximum":2281.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":962.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2248.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2281.11,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ankle, arthrography, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"73615","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":647.49,"maximum":719.29,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":647.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":714.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":719.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":719.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":714.25,"methodology":"fee schedule"}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC ","code_information":[{"code":"361","type":"RC"},{"code":"482","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (liver), surveillance for HCC in high-rish patients, analysis of methylation patterns on circulating cfDNA plus measurement of serum of APF/APF-L3 and oncoprotein DCP, algorithm reported as n ","code_information":[{"code":"0333U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1089.52,"maximum":2583.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1089.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2545.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1210.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1210.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2583.05,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels ","code_information":[{"code":"35571","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Angiography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75716","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":455.30,"maximum":505.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":455.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":502.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":505.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":505.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":502.25,"methodology":"fee schedule"}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis B virus ","code_information":[{"code":"307","type":"RC"},{"code":"87912","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":423.51,"maximum":1004.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":423.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":989.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1004.05,"methodology":"fee schedule"}]}]},{"description":"EPISTAXIS WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"150","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Platelets pheresis path re ","code_information":[{"code":"09536","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":569.66,"maximum":575.53,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":569.66,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":575.53,"methodology":"fee schedule"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH MCC ","code_information":[{"code":"155","type":"RC"},{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Nfct Agent HIV Trgt Viral Next-Gnrj Seq Alys Alg ","code_information":[{"code":"0219U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":580.00,"maximum":3087.63,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":739.50,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1267.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3087.63,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3086.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":739.50,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":739.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":725.00,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":727.16,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":580.00,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":754.00,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":734.66,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":728.62,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":725.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":725.00,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":754.00,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"296","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"AFTERCARE WITH CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less ","code_information":[{"code":"11640","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"207","type":"RC"},{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) ","code_information":[{"code":"78895","type":"CDM"},{"code":"81275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":154.60,"maximum":823.00,"gross_charge":2639.50,"discounted_cash":2639.50,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":197.12,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":337.78,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":823.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":822.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":197.12,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":197.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":564.08,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":640.99,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":512.81,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":640.99,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":491.34,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":193.25,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":193.83,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":154.60,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":200.98,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":195.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":194.22,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":193.25,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":193.25,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":200.98,"methodology":"fee schedule"}]}]},{"description":"Removal of implanted material, posterior segment; intraocular ","code_information":[{"code":"67121","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Beta amyloid, AB42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry and  ApoE isoform-specific peotyotyping, plasma combined with age ","code_information":[{"code":"0412U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1233.75,"maximum":2925.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1233.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2883.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1371.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1371.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2925.00,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion, esophagus, with primary repair; cervical approach ","code_information":[{"code":"43100","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Clostridium difficile toxin(s) antigen detection by immunoassay technique, stool, qualitative, multiple-step method ","code_information":[{"code":"0107U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.80,"maximum":68.14,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":16.32,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":27.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":68.14,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":68.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":16.32,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":16.32,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":46.70,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":53.07,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":42.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":53.07,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":40.68,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":16.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":12.80,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":16.64,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16.08,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":16.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":16.00,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":16.64,"methodology":"fee schedule"}]}]},{"description":"Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, fe ","code_information":[{"code":"0803T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CAROTID ARTERY STENT PROCEDURES WITH CC ","code_information":[{"code":"035","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Collection of capillary blood specimen (eg, finger, heel, ear stick) ","code_information":[{"code":"36416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":0.39,"maximum":0.39,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":0.39,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":0.39,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical ","code_information":[{"code":"400","type":"RC"},{"code":"72156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1682.06,"maximum":1868.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1682.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1855.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1868.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1868.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1855.51,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy an ","code_information":[{"code":"499","type":"RC"},{"code":"92944","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12481.00,"maximum":21869.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12481.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21869.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21869.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Tyrosine ","code_information":[{"code":"309","type":"RC"},{"code":"84510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.49,"maximum":41.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":40.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":41.46,"methodology":"fee schedule"}]}]},{"description":"INBORN AND OTHER DISORDERS OF METABOLISM ","code_information":[{"code":"111","type":"RC"},{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon ","code_information":[{"code":"26410","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"FEVER AND INFLAMMATORY CONDITIONS ","code_information":[{"code":"167","type":"RC"},{"code":"864","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair ","code_information":[{"code":"11451","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Application of long leg cast brace ","code_information":[{"code":"29358","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, colon ","code_information":[{"code":"45399","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Colposcopy of the vulva; with biopsy(s) ","code_information":[{"code":"490","type":"RC"},{"code":"56821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm ","code_information":[{"code":"27047","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Evisceration of ocular contents; without implant ","code_information":[{"code":"65091","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC ","code_information":[{"code":"141","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy ","code_information":[{"code":"361","type":"RC"},{"code":"56640","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PERSONALITY AND IMPULSE CONTROL  IPF","code_information":[{"code":"126","type":"RC"},{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1337.88,"maximum":1337.88,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1337.88,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint ","code_information":[{"code":"26531","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Cortisol; total ","code_information":[{"code":"300","type":"RC"},{"code":"82533","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.81,"maximum":63.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63.57,"methodology":"fee schedule"}]}]},{"description":"Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system ","code_information":[{"code":"33264","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34061.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37708.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":37844.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":37844.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37708.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedu ","code_information":[{"code":"15261","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Amputation, leg, through tibia and fibula; secondary closure or scar revision ","code_information":[{"code":"27884","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Medial canthopexy (separate procedure) ","code_information":[{"code":"21280","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITHOUT MCC ","code_information":[{"code":"123","type":"RC"},{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); INCARCERATED OR STRANGULATED ","code_information":[{"code":"49572","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur ","code_information":[{"code":"27185","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC ","code_information":[{"code":"499","type":"RC"},{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Disarticulation of hip ","code_information":[{"code":"27295","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Repair of entropion; suture ","code_information":[{"code":"360","type":"RC"},{"code":"67921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, foot; 2 views ","code_information":[{"code":"73620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.82,"maximum":405.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":405.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":405.00,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":90.00,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":102.28,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":81.82,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":102.28,"methodology":"fee schedule"}]}]},{"description":"Blood count; reticulocytes, automated, including 1 or more cellular parameters (eg, reticulocyte hemoglobin content ºCHr», immature reticulocyte fraction ºIRF», reticulocyte volume ºMRV», RNA content) ","code_information":[{"code":"309","type":"RC"},{"code":"85046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.16,"maximum":21.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21.72,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, intercarpal or carpometacarpal joints; suspension, including transfer or transplant of tendon, with interposition, when performed ","code_information":[{"code":"25448","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Prescription drug monitoring, evaluation of 65 common drug by LCMS/MS, urine, each drug reported detected or not detected ","code_information":[{"code":"0093U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":102.22,"maximum":242.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":102.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":238.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":113.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":113.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":242.35,"methodology":"fee schedule"}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"153","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC  IPF","code_information":[{"code":"156","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1531.28,"maximum":1531.28,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1531.28,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure) ","code_information":[{"code":"35306","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors, each ","code_information":[{"code":"300","type":"RC"},{"code":"86977","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments ","code_information":[{"code":"22812","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":26605.10,"maximum":83200.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":67500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":75000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":75000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY ","code_information":[{"code":"113","type":"RC"},{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC ","code_information":[{"code":"155","type":"RC"},{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HEART FAILURE AND SHOCK WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure) ","code_information":[{"code":"61210","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC ","code_information":[{"code":"115","type":"RC"},{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Upper facial prosthesis, provided by a non-physician ","code_information":[{"code":"L8043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3826.74,"maximum":8360.94,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":4879.09,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":8360.94,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":4879.09,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":4879.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":4783.42,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":4639.92,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":3826.74,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":4974.76,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":4687.75,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4807.34,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":4783.42,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":4783.42,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":4974.76,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITH CC ","code_information":[{"code":"137","type":"RC"},{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sympathectomy; digital arteries, each digit ","code_information":[{"code":"64820","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon ","code_information":[{"code":"300","type":"RC"},{"code":"86480","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":101.96,"maximum":241.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":101.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":238.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":113.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":113.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":241.72,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; influenza B virus ","code_information":[{"code":"305","type":"RC"},{"code":"87275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.15,"maximum":47.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":47.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47.77,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular) ","code_information":[{"code":"27614","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Ligation of inferior vena cava ","code_information":[{"code":"37619","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid ","code_information":[{"code":"360","type":"RC"},{"code":"41006","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Lenticular, (myodisc), per lens, single vision ","code_information":[{"code":"V2115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":71.02,"maximum":155.18,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":90.56,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":155.18,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":90.56,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":90.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":88.78,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":86.12,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":71.02,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":92.33,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":87.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":89.22,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":88.78,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":88.78,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":92.33,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique ","code_information":[{"code":"302","type":"RC"},{"code":"87580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.98,"maximum":78.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.20,"methodology":"fee schedule"}]}]},{"description":"CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) ","code_information":[{"code":"305","type":"RC"},{"code":"81190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"Lipoprotein-associated phospholipase A2 (Lp-PLA2) ","code_information":[{"code":"83698","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":76.18,"maximum":180.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":76.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":178.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":84.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":84.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":180.61,"methodology":"fee schedule"}]}]},{"description":"Quinupristin/dalfopristin ","code_information":[{"code":"2770","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":3.41,"maximum":7.45,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":4.35,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":7.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":4.35,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":4.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":3.41,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":4.43,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.28,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":4.26,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":4.43,"methodology":"fee schedule"}]}]},{"description":"Radical resection of sternum; with mediastinal lymphadenectomy ","code_information":[{"code":"21632","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Tenodesis of biceps tendon at elbow (separate procedure) ","code_information":[{"code":"24340","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M ","code_information":[{"code":"141","type":"RC"},{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less ","code_information":[{"code":"11310","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"361","type":"RC"},{"code":"49442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Ethmoidectomy; extranasal, total ","code_information":[{"code":"31205","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lat ","code_information":[{"code":"61618","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components ","code_information":[{"code":"43774","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":33726.00,"maximum":53343.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":33726.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53343.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":37473.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":37473.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53343.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of implanted intra-arterial infusion pump ","code_information":[{"code":"361","type":"RC"},{"code":"36262","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal ","code_information":[{"code":"369","type":"RC"},{"code":"44020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MSH2 (mutS homolog 2) (eg, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (List separately in addition to code for primary procedure) ","code_information":[{"code":"0159U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":465.34,"maximum":1103.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":465.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1087.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":517.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":517.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1103.23,"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":"323","type":"RC"},{"code":"77338","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":1303.04,"maximum":1447.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1303.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1437.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1447.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1447.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1437.40,"methodology":"fee schedule"}]}]},{"description":"Application of multi-layer compression system; upper arm, forearm, hand, and fingers ","code_information":[{"code":"29584","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external (Scribner type) ","code_information":[{"code":"36810","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Histamine ","code_information":[{"code":"303","type":"RC"},{"code":"83088","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":48.58,"maximum":115.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":48.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":113.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":53.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":115.17,"methodology":"fee schedule"}]}]},{"description":"Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein interposition ","code_information":[{"code":"35881","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a combination A of NGS, San ","code_information":[{"code":"0101U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1924.60,"maximum":4562.88,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1924.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4497.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2138.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2138.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4562.88,"methodology":"fee schedule"}]}]},{"description":"Biopsy; nasopharynx, survey for unknown primary lesion ","code_information":[{"code":"42806","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Gastric intubation and aspiration, diagnostic; single specimen (eg, acid analysis) ","code_information":[{"code":"43754","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Synovectomy; intertarsal or tarsometatarsal joint, each ","code_information":[{"code":"28070","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar ","code_information":[{"code":"0221T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) ","code_information":[{"code":"13153","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Biliary endoscopy, percutaneous via T-tube or other tract; with removal of calculus/calculi ","code_information":[{"code":"47554","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE ","code_information":[{"code":"169","type":"RC"},{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of implant from finger or hand ","code_information":[{"code":"26320","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiopharmaceutical therapy, by intravenous administration ","code_information":[{"code":"341","type":"RC"},{"code":"79101","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":281.11,"maximum":312.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":281.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":310.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":312.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":312.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":310.09,"methodology":"fee schedule"}]}]},{"description":"Ostectomy, excision of tarsal coalition ","code_information":[{"code":"28116","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification ","code_information":[{"code":"87512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":33.41,"maximum":177.82,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":42.60,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":72.99,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":177.82,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":177.77,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":42.60,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":42.60,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":135.44,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":153.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":123.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":153.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":117.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":41.76,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":41.88,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":33.41,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":43.43,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":42.32,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":41.97,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":41.76,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":41.76,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":43.43,"methodology":"fee schedule"}]}]},{"description":"Antibody; Listeria monocytogenes ","code_information":[{"code":"301","type":"RC"},{"code":"86723","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.70,"maximum":51.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.44,"methodology":"fee schedule"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) Sleep Studies","code_information":[{"code":"920","type":"RC"},{"code":"95806","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1651.00,"maximum":3498.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1651.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3498.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1834.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1834.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3498.00,"methodology":"case rate"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Nephelometry, each analyte not elsewhere specified ","code_information":[{"code":"307","type":"RC"},{"code":"83883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.37,"maximum":53.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.04,"methodology":"fee schedule"}]}]},{"description":"Bone age studies ","code_information":[{"code":"321","type":"RC"},{"code":"77072","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":132.61,"maximum":147.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":132.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":146.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":147.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":147.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":146.29,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) ","code_information":[{"code":"300","type":"RC"},{"code":"87623","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Antibody; HIV-1 ","code_information":[{"code":"58194","type":"CDM"},{"code":"86701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.11,"maximum":37.87,"gross_charge":569.25,"discounted_cash":569.25,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9.07,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":15.54,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":37.87,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":37.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9.07,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":9.07,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":32.02,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":36.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":29.11,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":36.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":27.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8.89,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":7.11,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9.25,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":9.01,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8.93,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":8.89,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":8.89,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":8.15,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":9.25,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with irrigation and evacuation of multiple obstructing clots ","code_information":[{"code":"369","type":"RC"},{"code":"52001","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Storage (per year); embryo(s) ","code_information":[{"code":"304","type":"RC"},{"code":"89342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cm ","code_information":[{"code":"21935","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"In111 ibritumomab, dx ","code_information":[{"code":"769","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":638.42,"maximum":1394.86,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":813.98,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1394.86,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":813.98,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":813.98,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":798.02,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":638.42,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":829.94,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":802.01,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":798.02,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":798.02,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":829.94,"methodology":"fee schedule"}]}]},{"description":"Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological ","code_information":[{"code":"369","type":"RC"},{"code":"50435","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"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":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":102.22,"maximum":242.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":102.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":238.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":113.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":113.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":242.35,"methodology":"fee schedule"}]}]},{"description":"Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (8 ","code_information":[{"code":"80053","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.37,"maximum":41.18,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":40.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":41.18,"methodology":"fee schedule"}]}]},{"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":136.16,"maximum":151.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":136.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":150.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":151.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":151.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":150.20,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC ","code_information":[{"code":"085","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT ","code_information":[{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":53895.90,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":85851.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":76469.330,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":85851.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":85851.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8371.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14520.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53895.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16134.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":59890.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":15913.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16134.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":43660.72,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":23798.21,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":15913.07,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":92534.320,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":102815.910,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":8208.73,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":28274.380,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":32142.820,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":25703.980,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":32142.820,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":57846.800,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":15601.05,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":12480.84,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":36833.800,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":68102.690,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":36833.800,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":16225.09,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":122093.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":54749.470,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":34314.810,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15039.41,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":78782.690,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":15601.05,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":15601.05,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":8737.02,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":16069.08,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of calcaneal fracture; without manipulation ","code_information":[{"code":"28400","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"SEIZURES WITH MCC ","code_information":[{"code":"100","type":"MS-DRG"},{"code":"100","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy; nasopharynx, visible lesion, simple ","code_information":[{"code":"369","type":"RC"},{"code":"42804","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"REHABILITATION WITHOUT CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas ","code_information":[{"code":"0420T","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with dilation, initial ","code_information":[{"code":"31528","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Excision of neuroma; hand or foot, except digital nerve ","code_information":[{"code":"64782","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Level 1 Minor Procedures ","code_information":[{"code":"5731","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":21.34,"maximum":46.62,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":27.21,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":46.62,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":27.21,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":27.21,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":26.67,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":21.34,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":27.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":26.81,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":26.67,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":26.67,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":27.74,"methodology":"fee schedule"}]}]},{"description":"Gastrectomy, total; with Roux-en-Y reconstruction ","code_information":[{"code":"43621","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger than 12 years of age ","code_information":[{"code":"31551","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies ","code_information":[{"code":"27331","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19023.00,"maximum":22929.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, abdomen; 2 views ","code_information":[{"code":"329","type":"RC"},{"code":"74019","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":191.88,"maximum":213.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":191.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":211.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":213.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":213.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":211.66,"methodology":"fee schedule"}]}]},{"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthroplasty, elbow; with implant and fascia lata ligament reconstruction ","code_information":[{"code":"24362","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11152.90,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Ocular surface reconstruction; amniotic membrane transplantation, multiple layers ","code_information":[{"code":"65780","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Spinal puncture, lumbar, diagnostic; ","code_information":[{"code":"361","type":"RC"},{"code":"62270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed ","code_information":[{"code":"300","type":"RC"},{"code":"81161","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":458.95,"maximum":1088.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":458.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1072.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":510.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":510.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1088.10,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ankle; complete, minimum of 3 views ","code_information":[{"code":"322","type":"RC"},{"code":"73610","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":42.10,"maximum":46.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":42.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":46.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":46.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.44,"methodology":"fee schedule"}]}]},{"description":"Nerve pedicle transfer; first stage ","code_information":[{"code":"64905","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, with single or multiple bronchial or endobronchial biopsy(ies), single or multiple sites, with transendoscopic endobronchial ultrasound (ebus) during bronchoscopic dia ","code_information":[{"code":"490","type":"RC"},{"code":"C7512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision distal ulna partial or complete (eg, Darrach type or matched resection) ","code_information":[{"code":"25240","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Ostectomy, excision of tarsal coalition ","code_information":[{"code":"28116","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) ","code_information":[{"code":"301","type":"RC"},{"code":"37201","type":"CDM"},{"code":"80061","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.03,"maximum":52.22,"gross_charge":371.75,"discounted_cash":371.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.22,"methodology":"fee schedule"}]}]},{"description":"Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculograp ","code_information":[{"code":"0824T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, micafungin sodium (par pharm) not thereapeutically equivalent to j2248, 1 mg ","code_information":[{"code":"J2247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.30,"maximum":0.88,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.88,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":0.83,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":0.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":0.38,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.34,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":0.43,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.30,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.30,"methodology":"fee schedule"}]}]},{"description":"Injection, thiamine hcl, 100 mg ","drug_information":{"unit":"100","type":"ME"},"code_information":[{"code":"72889","type":"CDM"},{"code":"J3411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.71,"maximum":4.72,"gross_charge":76.25,"discounted_cash":76.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":2.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3.47,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":4.72,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":4.72,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":2.14,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":2.43,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1.95,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":2.43,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1.71,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1.72,"methodology":"fee schedule"}]}]},{"description":"Infectious disease (bacterial or viral), biochemical assays, tumor necrosis factor related apoptosis-inducing ligand interferon gamma induced protein-10, and C-reactive protein, serum, algorithm repor ","code_information":[{"code":"0351U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":428.52,"maximum":1015.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":428.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1001.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":476.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":476.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1015.95,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments ","code_information":[{"code":"22812","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":123521.00,"maximum":123521.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":123521.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":123521.00,"methodology":"case rate"}]}]},{"description":"Optic nerve decompression (eg, incision or fenestration of optic nerve sheath) ","code_information":[{"code":"67570","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Etiocholanolone ","code_information":[{"code":"82696","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":43.16,"maximum":102.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":43.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":100.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":47.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":47.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":102.34,"methodology":"fee schedule"}]}]},{"description":"Radiologic small intestine follow-through study, including multiple serial images (List separately in addition to code for primary procedure for upper GI radiologic examination) ","code_information":[{"code":"321","type":"RC"},{"code":"74248","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":166.59,"maximum":185.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":166.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":183.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":185.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":185.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":183.76,"methodology":"fee schedule"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) ","code_information":[{"code":"307","type":"RC"},{"code":"81224","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":277.59,"maximum":658.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":277.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":648.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":308.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":308.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":658.13,"methodology":"fee schedule"}]}]},{"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":"369","type":"RC"},{"code":"63020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Repair inguinal hernia, sliding, any age ","code_information":[{"code":"361","type":"RC"},{"code":"49525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Repair of defect with autograft; radius OR ulna ","code_information":[{"code":"25425","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy ","code_information":[{"code":"21743","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Ultrasound, abdominal, real time with image documentation; complete ","code_information":[{"code":"402","type":"RC"},{"code":"76700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":597.42,"maximum":663.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":597.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":659.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":663.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":663.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":659.02,"methodology":"fee schedule"}]}]},{"description":"Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors ","code_information":[{"code":"25115","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Hemoglobin; thermolabile ","code_information":[{"code":"306","type":"RC"},{"code":"83065","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.80,"maximum":35.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":34.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":16.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":16.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35.10,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"151","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sodium; other source ","code_information":[{"code":"38779","type":"CDM"},{"code":"84302","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.89,"maximum":20.70,"gross_charge":164.50,"discounted_cash":164.50,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":4.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":4.96,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":8.49,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":20.70,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":20.69,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":4.96,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":4.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":15.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":17.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":14.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":17.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":13.73,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":4.86,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":4.88,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":3.89,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":5.05,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":4.93,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":4.88,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":4.86,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":4.86,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":4.45,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":5.05,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transcatheter septal reduction therapy (eg, alcohol septal ablation) including temporary pacemaker insertion when performed ","code_information":[{"code":"790","type":"RC"},{"code":"93583","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"361","type":"RC"},{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy ","code_information":[{"code":"21743","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"036","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation ","code_information":[{"code":"481","type":"RC"},{"code":"67210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":" Room & Board - Three and Four Beds Psychiatriac  Adult","code_information":[{"code":"134","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1096.00,"maximum":6500.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4095.00,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6500.00,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4550.00,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4550.00,"methodology":"per diem"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5500.00,"methodology":"per diem"},{"payer_name":"United Behavioral Health","plan_name":"BHCOMM","standard_charge_dollar":1454.00,"methodology":"per diem"},{"payer_name":"United Behavioral Health","plan_name":"MCR","standard_charge_dollar":1096.00,"methodology":"per diem"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy of floor of mouth ","code_information":[{"code":"361","type":"RC"},{"code":"41108","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Renal autotransplantation, reimplantation of kidney ","code_information":[{"code":"481","type":"RC"},{"code":"50380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of extraparenchymal lesion of testis ","code_information":[{"code":"360","type":"RC"},{"code":"54512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) ","code_information":[{"code":"15825","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Keratoplasty (corneal transplant); anterior lamellar ","code_information":[{"code":"361","type":"RC"},{"code":"65710","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level ","code_information":[{"code":"64483","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC ","code_information":[{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":26105.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":48685.730,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":43365.280,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":48685.730,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":48685.730,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7232.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6505.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":24147.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7228.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":33963.400,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":7129.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7228.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19561.51,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":10662.42,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":7129.61,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":52475.640,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":58306.260,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":7092.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":16034.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":18228.000,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":14576.570,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":18228.000,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":32804.560,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":6989.81,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":5591.85,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":20888.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":38620.610,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":20888.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":7269.40,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":69238.690,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":31048.090,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":19459.720,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6738.18,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":44677.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":6989.81,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":6989.81,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":7548.54,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":7199.51,"methodology":"fee schedule"}]}]},{"description":"FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY ","code_information":[{"code":"138","type":"RC"},{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism ","code_information":[{"code":"300","type":"RC"},{"code":"87797","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.40,"maximum":117.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":49.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":115.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":54.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":54.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":117.12,"methodology":"fee schedule"}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion Gamma Knife","code_information":[{"code":"333","type":"RC"},{"code":"61796","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate"}]}]},{"description":"Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less ","code_information":[{"code":"14060","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthrotomy with biopsy; carpometacarpal joint, each ","code_information":[{"code":"26100","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Manipulation, wrist, under anesthesia ","code_information":[{"code":"25259","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); REDUCIBLE ","code_information":[{"code":"49656","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_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":1031.80,"maximum":1146.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1031.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1138.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1146.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1146.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1138.20,"methodology":"fee schedule"}]}]},{"description":"Bypass graft; autogenous composite, 2 segments of veins from 2 locations (List separately in addition to code for primary procedure) ","code_information":[{"code":"35682","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Coagulation time; activated ","code_information":[{"code":"306","type":"RC"},{"code":"85347","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.04,"maximum":16.69,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.69,"methodology":"fee schedule"}]}]},{"description":"Injection, ramucirumab ","code_information":[{"code":"1488","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":59.49,"maximum":129.97,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":75.85,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":129.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":75.85,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":75.85,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":74.36,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":59.49,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":77.33,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":74.73,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":74.36,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":74.36,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":77.33,"methodology":"fee schedule"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITH MCC ","code_information":[{"code":"080","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Inj mosunetuzumab-axgb, 1 ","code_information":[{"code":"9150","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":523.70,"maximum":1144.23,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":667.72,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1144.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":667.72,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":667.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":654.63,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":523.70,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":680.81,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":657.90,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":654.63,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":654.63,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":680.81,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, sacroiliac joints; 3 or more views ","code_information":[{"code":"323","type":"RC"},{"code":"72202","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":204.11,"maximum":226.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":204.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":225.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":226.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":226.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":225.16,"methodology":"fee schedule"}]}]},{"description":"Endomyocardial biopsy ","code_information":[{"code":"369","type":"RC"},{"code":"93505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Free osteocutaneous flap with microvascular anastomosis; great toe with web space ","code_information":[{"code":"20973","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Cephalin floculation, blood ","code_information":[{"code":"305","type":"RC"},{"code":"P2028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.14,"maximum":19.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.30,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"124","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1102.74,"maximum":1124.80,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1124.80,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1102.74,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code for primary procedure) ","code_information":[{"code":"301","type":"RC"},{"code":"81416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19740.00,"maximum":46800.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19740.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46128.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21936.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21936.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46800.00,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty with prosthetic replacement; distal ulna ","code_information":[{"code":"25442","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Computed tomography, head or brain; with contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"70460","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":512.20,"maximum":569.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":512.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":565.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":569.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":569.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":565.02,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body ","code_information":[{"code":"29904","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Laminectomy with rhizotomy; more than 2 segments ","code_information":[{"code":"63190","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common variants (eg, E285A, Y231X) ","code_information":[{"code":"81200","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":77.73,"maximum":184.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":77.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":181.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":86.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":86.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":184.28,"methodology":"fee schedule"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC ","code_information":[{"code":"147","type":"MS-DRG"},{"code":"202","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfascial ","code_information":[{"code":"0819T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of foreign body, external eye; conjunctival superficial ","code_information":[{"code":"65205","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"PCA3/KLK3 (prostate cancer antigen 3 ºnon-protein coding»/kallikrein-related peptidase 3 ºprostate specific antigen») ratio (eg, prostate cancer) ","code_information":[{"code":"303","type":"RC"},{"code":"81313","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":419.56,"maximum":994.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":419.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":980.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":466.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":466.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":994.70,"methodology":"fee schedule"}]}]},{"description":"Removal of intra-aortic balloon assist device, percutaneous ","code_information":[{"code":"33968","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Implantation of Drug Infus ","code_information":[{"code":"5471","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":15399.10,"maximum":33645.12,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":19633.86,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":33645.12,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":19633.86,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":19633.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":19248.88,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":15399.10,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":20018.84,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19345.12,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":19248.88,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":19248.88,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":20018.84,"methodology":"fee schedule"}]}]},{"description":"Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including s ","code_information":[{"code":"19081","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Receptor assay; progesterone ","code_information":[{"code":"300","type":"RC"},{"code":"84234","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":106.73,"maximum":253.03,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":106.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":249.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":118.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":118.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":253.03,"methodology":"fee schedule"}]}]},{"description":"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC ","code_information":[{"code":"481","type":"RC"},{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation ","code_information":[{"code":"77021","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1365.19,"maximum":1706.50,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1501.71,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1706.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1365.19,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1706.50,"methodology":"fee schedule"}]}]},{"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":"62370","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code f ","code_information":[{"code":"64634","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"307","type":"RC"},{"code":"81271","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"Venous anastomosis, open; portocaval ","code_information":[{"code":"369","type":"RC"},{"code":"37140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"154","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1168.64,"maximum":1192.01,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1192.01,"methodology":"fee schedule","additional_payer_notes":"Days 5. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1168.64,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Computed tomography, upper extremity; with contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"73201","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":274.84,"maximum":305.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":274.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":303.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":305.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":305.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":303.17,"methodology":"fee schedule"}]}]},{"description":"Alpha-fetoprotein (AFP); serum ","code_information":[{"code":"303","type":"RC"},{"code":"82105","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.59,"maximum":65.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.40,"methodology":"fee schedule"}]}]},{"description":"Valvotomy, mitral valve; open heart, with cardiopulmonary bypass ","code_information":[{"code":"33422","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"146","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":880.79,"maximum":880.79,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":880.79,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Mastotomy with exploration or drainage of abscess, deep ","code_information":[{"code":"19020","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Level 2 hospital emergency department visit provided in a type b emergency department; (the ed must meet at least one of the following requirements: (1) it is licensed by the state in which it is loca ","code_information":[{"code":"450","type":"RC"},{"code":"G0381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":810.00,"maximum":1803.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":810.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1803.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":900.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":900.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1803.00,"methodology":"case rate"}]}]},{"description":"Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"321","type":"RC"},{"code":"77080","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":47.13,"maximum":52.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":47.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":52.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":52.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.99,"methodology":"fee schedule"}]}]},{"description":"Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) ","code_information":[{"code":"21127","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Nephrectomy with total ureterectomy and bladder cuff; through same incision ","code_information":[{"code":"50234","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Voriconazole ","code_information":[{"code":"307","type":"RC"},{"code":"80285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.60,"maximum":105.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":104.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":49.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":49.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":105.73,"methodology":"fee schedule"}]}]},{"description":"Prealbumin ","code_information":[{"code":"300","type":"RC"},{"code":"84134","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.00,"maximum":56.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":56.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.90,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) ","code_information":[{"code":"24115","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Computed tomography, lumbar spine; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"72131","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":236.13,"maximum":262.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":236.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":260.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":262.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":262.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":260.48,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Fusion in opposition, thumb, with autogenous graft (includes obtaining graft) ","code_information":[{"code":"26820","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Babesia microti, amplified probe technique ","code_information":[{"code":"300","type":"RC"},{"code":"87469","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"101","type":"RC"},{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, by radioimmunoassay (eg, RIA) ","code_information":[{"code":"305","type":"RC"},{"code":"83519","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.27,"maximum":71.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":70.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":71.76,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, a ","code_information":[{"code":"480","type":"RC"},{"code":"C9608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":18354.00,"maximum":32402.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18354.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":32402.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":32402.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"136","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1135.93,"maximum":1135.93,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1135.93,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Perineogram (eg, vaginogram, for sex determination or extent of anomalies) ","code_information":[{"code":"323","type":"RC"},{"code":"74775","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":148.29,"maximum":164.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":148.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":163.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":164.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":164.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":163.58,"methodology":"fee schedule"}]}]},{"description":"Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; with tapering ","code_information":[{"code":"44127","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC ","code_information":[{"code":"203","type":"RC"},{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each ","code_information":[{"code":"0669T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies ","code_information":[{"code":"45121","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial ","code_information":[{"code":"29895","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Percutaneous transcatheter thermal ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance ","code_information":[{"code":"0793T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral ","code_information":[{"code":"0718T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Inj tisotu vedotin-tftv, 1 ","code_information":[{"code":"9204","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":151.01,"maximum":329.93,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":329.93,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":192.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":188.76,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":151.01,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":196.31,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":189.70,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":188.76,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":188.76,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":196.31,"methodology":"fee schedule"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"167","type":"RC"},{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent ","code_information":[{"code":"307","type":"RC"},{"code":"87190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.02,"maximum":28.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.51,"methodology":"fee schedule"}]}]},{"description":"Phosphatase, alkaline; isoenzymes ","code_information":[{"code":"84080","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":24.31,"maximum":57.64,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":56.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":57.64,"methodology":"fee schedule"}]}]},{"description":"DIABETES WITH MCC ","code_information":[{"code":"153","type":"RC"},{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance ","code_information":[{"code":"369","type":"RC"},{"code":"61751","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"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":"50431","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Arthroplasty, temporomandibular joint, with allograft ","code_information":[{"code":"21242","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Hepatitis C antibody; ","code_information":[{"code":"86803","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":23.47,"maximum":55.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":55.65,"methodology":"fee schedule"}]}]},{"description":"Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-thoracic, single or multiple ","code_information":[{"code":"32553","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"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":"C9760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21416.00,"maximum":25567.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21416.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":25567.00,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and r ","code_information":[{"code":"0269T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe ","code_information":[{"code":"20969","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, chest; 2 views ","code_information":[{"code":"324","type":"RC"},{"code":"71046","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":122.18,"maximum":135.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":122.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":135.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":135.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":134.78,"methodology":"fee schedule"}]}]},{"description":"Biopsy of liver, wedge ","code_information":[{"code":"47100","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) ","code_information":[{"code":"305","type":"RC"},{"code":"88364","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":180.23,"maximum":427.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":180.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":421.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":200.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":200.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":427.28,"methodology":"fee schedule"}]}]},{"description":"Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for ","code_information":[{"code":"36410","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"RED BLOOD CELL DISORDERS WITHOUT MCC ","code_information":[{"code":"211","type":"RC"},{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, temporomandibular joint, open and closed mouth; bilateral ","code_information":[{"code":"322","type":"RC"},{"code":"70330","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":218.45,"maximum":242.68,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":218.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":240.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":242.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":242.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":240.97,"methodology":"fee schedule"}]}]},{"description":"Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"481","type":"RC"},{"code":"57061","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular ele ","code_information":[{"code":"0411T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC ","code_information":[{"code":"121","type":"RC"},{"code":"125","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Endolymphatic sac operation; with shunt ","code_information":[{"code":"360","type":"RC"},{"code":"69806","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"149","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) ","code_information":[{"code":"29805","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array ","code_information":[{"code":"360","type":"RC"},{"code":"61885","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":63632.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36318.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"169","type":"RC"},{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or neck ","code_information":[{"code":"24145","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, shoulder; 1 view ","code_information":[{"code":"320","type":"RC"},{"code":"73020","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":37.01,"maximum":41.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":37.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":40.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":41.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40.82,"methodology":"fee schedule"}]}]},{"description":"Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA ","code_information":[{"code":"0493U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4529.10,"maximum":10737.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4529.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10583.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5032.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5032.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":10737.67,"methodology":"fee schedule"}]}]},{"description":"Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixation ","code_information":[{"code":"27846","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC ","code_information":[{"code":"987","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":21863.51,"maximum":22088.91,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":21863.51,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":22088.91,"methodology":"fee schedule"}]}]},{"description":"Flow cytometry, cell cycle or DNA analysis ","code_information":[{"code":"310","type":"RC"},{"code":"88182","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.86,"maximum":194.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":194.06,"methodology":"fee schedule"}]}]},{"description":"Lateral canthopexy ","code_information":[{"code":"21282","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Removal of ventricular assist device; extracorporeal, biventricular ","code_information":[{"code":"33978","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; axillary-brachial ","code_information":[{"code":"35321","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bi-iliac prosthesis ","code_information":[{"code":"34831","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"HLA Class I typing, low resolution (eg, antigen equivalents); one locus (eg, HLA-A, -B, or -C), each ","code_information":[{"code":"81373","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":209.62,"maximum":496.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":209.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":489.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":232.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":232.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":496.98,"methodology":"fee schedule"}]}]},{"description":"Lower extremity fascial plane block, unilateral; by injection(s), including imaging guidance, when performed ","code_information":[{"code":"499","type":"RC"},{"code":"64473","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Iodine i-125, sodium iodide solution, therapeutic, per millicurie ","code_information":[{"code":"A9527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":66.50,"maximum":469.03,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":469.03,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":469.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":73.16,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":83.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":66.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":83.13,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) ","code_information":[{"code":"499","type":"RC"},{"code":"52352","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Injection, corticorelin ovine triflutate, 1 microgram ","code_information":[{"code":"J0795","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.01,"maximum":24.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.02,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":24.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":24.97,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":11.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":10.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":13.36,"methodology":"fee schedule"}]}]},{"description":"CELLULITIS WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Laryngectomy; total, with radical neck dissection ","code_information":[{"code":"31365","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Atomic absorption spectroscopy, each analyte ","code_information":[{"code":"307","type":"RC"},{"code":"82190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.16,"maximum":62.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.01,"methodology":"fee schedule"}]}]},{"description":"Orbital implant (implant outside muscle cone); removal or revision ","code_information":[{"code":"369","type":"RC"},{"code":"67560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and ","code_information":[{"code":"15121","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes obtaining graft) ","code_information":[{"code":"28102","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthroplasty, intercarpal or carpometacarpal joints; suspension, including transfer or transplant of tendon, with interposition, when performed ","code_information":[{"code":"25448","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Graft for facial nerve paralysis; regional muscle transfer ","code_information":[{"code":"15845","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each ","code_information":[{"code":"27686","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Puncture aspiration of cyst of breast; ","code_information":[{"code":"19000","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for ","code_information":[{"code":"300","type":"RC"},{"code":"81411","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2221.06,"maximum":5265.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2221.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5190.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2468.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2468.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5265.74,"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":"342","type":"RC"},{"code":"78801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1273.43,"maximum":1414.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1273.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1404.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1414.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1414.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1404.74,"methodology":"fee schedule"}]}]},{"description":"Strabismus surgery, recession or resection procedure; 2 horizontal muscles ","code_information":[{"code":"67312","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score ","code_information":[{"code":"319","type":"RC"},{"code":"81542","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6371.09,"maximum":15104.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6371.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14887.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15104.70,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of interphalangeal joint dislocation; requiring anesthesia ","code_information":[{"code":"28665","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Transection or avulsion of; supraorbital nerve ","code_information":[{"code":"64732","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery ","code_information":[{"code":"490","type":"RC"},{"code":"61705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"HEADACHES WITH MCC ","code_information":[{"code":"102","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closure of vesicouterine fistula; ","code_information":[{"code":"369","type":"RC"},{"code":"51920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Unlisted procedure, male genital system ","code_information":[{"code":"55899","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Pancreatectomy, total ","code_information":[{"code":"48155","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List ","code_information":[{"code":"22552","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":26550.00,"maximum":35000.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26550.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"750","type":"RC"},{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thoracoplasty, Schede type or extrapleural (all stages); ","code_information":[{"code":"32905","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; ","code_information":[{"code":"490","type":"RC"},{"code":"58550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Biopsy; nasopharynx, survey for unknown primary lesion ","code_information":[{"code":"360","type":"RC"},{"code":"42806","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions ","code_information":[{"code":"11200","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"URETHRAL STRICTURE ","code_information":[{"code":"202","type":"RC"},{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique ","code_information":[{"code":"307","type":"RC"},{"code":"87531","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":95.41,"maximum":226.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":95.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":222.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":106.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":106.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":226.20,"methodology":"fee schedule"}]}]},{"description":"Revision (including removal) of prosthetic vaginal graft; open abdominal approach ","code_information":[{"code":"361","type":"RC"},{"code":"57296","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan ","code_information":[{"code":"400","type":"RC"},{"code":"77338","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":1303.04,"maximum":1447.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1303.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1437.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1447.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1447.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1437.40,"methodology":"fee schedule"}]}]},{"description":"Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) ","code_information":[{"code":"24301","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Blood bank physician services; authorization for deviation from standard blood banking procedures (eg, use of outdated blood, transfusion of Rh incompatible units), with written report ","code_information":[{"code":"309","type":"RC"},{"code":"86079","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.86,"maximum":194.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":194.06,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; ilioiliac ","code_information":[{"code":"35563","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles ","code_information":[{"code":"304","type":"RC"},{"code":"81234","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral ","code_information":[{"code":"369","type":"RC"},{"code":"63268","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences ","code_information":[{"code":"320","type":"RC"},{"code":"74183","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":523.51,"maximum":581.56,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":523.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":577.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":581.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":581.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":577.49,"methodology":"fee schedule"}]}]},{"description":"Open treatment of nasal fracture; with concomitant open treatment of fractured septum ","code_information":[{"code":"21335","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) ","code_information":[{"code":"323","type":"RC"},{"code":"75565","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":59.01,"maximum":65.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":59.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":65.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":65.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":65.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.09,"methodology":"fee schedule"}]}]},{"description":" Peritoneal Dialysis - Outpatient or Home General Classification  ","code_information":[{"code":"830","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":744.00,"maximum":1578.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":744.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1578.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":827.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":827.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1578.00,"methodology":"case rate"}]}]},{"description":"Oncology (Plasma cell disorders and myeloma), circulating plasma cell immunologic selection, id, morphological characterization, and enumeration of plasma cells based on differential CD138, CD38, CD19 ","code_information":[{"code":"0337U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4005.57,"maximum":9496.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4005.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9360.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4451.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4451.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9496.50,"methodology":"fee schedule"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITHOUT MCC ","code_information":[{"code":"125","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies ","code_information":[{"code":"300","type":"RC"},{"code":"87806","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":53.91,"maximum":127.80,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":53.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":125.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":59.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":59.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":127.80,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, head or brain; with contrast material(s) ","code_information":[{"code":"400","type":"RC"},{"code":"70460","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":512.20,"maximum":569.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":512.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":565.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":569.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":569.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":565.02,"methodology":"fee schedule"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion ","code_information":[{"code":"11055","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails) ","code_information":[{"code":"26562","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, mastoids; less than 3 views per side ","code_information":[{"code":"321","type":"RC"},{"code":"70120","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":155.43,"maximum":172.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":155.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":171.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":172.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":172.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":171.46,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITHOUT MCC  IPF","code_information":[{"code":"136","type":"RC"},{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1170.54,"maximum":1170.54,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1170.54,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Transurethral destruction of prostate tissue; by microwave thermotherapy ","code_information":[{"code":"369","type":"RC"},{"code":"53850","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment ","code_information":[{"code":"329","type":"RC"},{"code":"77085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":280.23,"maximum":311.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":280.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":309.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":311.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":311.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":309.13,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC ","code_information":[{"code":"073","type":"MS-DRG"},{"code":"138","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive ","code_information":[{"code":"0272U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1000.44,"maximum":2371.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1000.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2337.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2371.86,"methodology":"fee schedule"}]}]},{"description":"Injection, pantoprazole sodium, 40 mg ","drug_information":{"unit":"40","type":"ME"},"code_information":[{"code":"121597","type":"CDM"},{"code":"J2470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.13,"maximum":12.44,"gross_charge":105.75,"discounted_cash":105.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":5.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8.14,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":12.44,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":12.44,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":5.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":6.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":5.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":6.41,"methodology":"fee schedule"}]}]},{"description":"Myocardial imaging, infarct avid, planar; qualitative or quantitative ","code_information":[{"code":"341","type":"RC"},{"code":"78466","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":158.67,"maximum":176.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":158.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":175.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":176.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":176.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":175.03,"methodology":"fee schedule"}]}]},{"description":"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC ","code_information":[{"code":"069","type":"MS-DRG"},{"code":"137","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Creatinine; other source ","code_information":[{"code":"82570","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.52,"maximum":20.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20.20,"methodology":"fee schedule"}]}]},{"description":"Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA ","code_information":[{"code":"0493U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4529.10,"maximum":10737.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4529.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10583.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5032.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5032.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":10737.67,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (Scianna blood group) genotyping (SC), gene analysis, ERMAP (erythroblast membrane associated protein) exons 4, 12 ","code_information":[{"code":"0199U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":452.10,"maximum":1071.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":452.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1056.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1071.84,"methodology":"fee schedule"}]}]},{"description":"Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA) ","code_information":[{"code":"0176U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":105.59,"maximum":250.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":105.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":246.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":117.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":117.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":250.34,"methodology":"fee schedule"}]}]},{"description":"Rheumatoid factor; qualitative ","code_information":[{"code":"86430","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10.10,"maximum":23.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":23.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":23.95,"methodology":"fee schedule"}]}]},{"description":"Donor cardiectomy (including cold preservation) ","code_information":[{"code":"33940","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1000.44,"maximum":2371.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1000.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2337.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2371.86,"methodology":"fee schedule"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITH CC/MCC ","code_information":[{"code":"121","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sternal debridement ","code_information":[{"code":"21627","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"BRONCHITIS AND ASTHMA WITH CC/MCC ","code_information":[{"code":"155","type":"RC"},{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC ","code_information":[{"code":"086","type":"MS-DRG"},{"code":"148","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique, includes reverse transcription when performed ","code_information":[{"code":"304","type":"RC"},{"code":"87538","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Antibody; Campylobacter ","code_information":[{"code":"86625","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":21.58,"maximum":51.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.17,"methodology":"fee schedule"}]}]},{"description":"Venous anastomosis, open; caval-mesenteric ","code_information":[{"code":"37160","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Removal and replacement of total replacement heart system (artificial heart) ","code_information":[{"code":"33928","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"207","type":"RC"},{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening ","code_information":[{"code":"27612","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Oncology (papillary thyroid cancer), gene-expression profiling via targeted hybrid capture-enrichment rna sequencing of 82 content genes and 10 housekeeping genes, formalin-fixed paraffin embedded (ff ","code_information":[{"code":"0362U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5922.00,"maximum":14040.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5922.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":13838.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6580.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6580.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14040.00,"methodology":"fee schedule"}]}]},{"description":"Repair of pulmonary artery arborization anomalies by unifocalization; with cardiopulmonary bypass ","code_information":[{"code":"33926","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only ","code_information":[{"code":"0531T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg ","code_information":[{"code":"J2427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12.29,"maximum":33.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":18.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":14.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22.43,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":33.85,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":33.85,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":15.35,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":17.44,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":13.95,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":17.44,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12.29,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12.42,"methodology":"fee schedule"}]}]},{"description":"Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1,BRCA1,CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1), formalin-fixed paraffin emb ","code_information":[{"code":"0288U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6371.09,"maximum":15104.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6371.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14887.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15104.70,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"670","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, hiv-1 and/or hiv-2, screening ","code_information":[{"code":"309","type":"RC"},{"code":"G0433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":30.09,"maximum":71.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":70.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":71.33,"methodology":"fee schedule"}]}]},{"description":"Excision, trochanteric pressure ulcer, with primary suture; with ostectomy ","code_information":[{"code":"15951","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19023.00,"maximum":22929.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"130","type":"RC"},{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC ","code_information":[{"code":"094","type":"MS-DRG"},{"code":"138","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Carbohydrate deficient transferrin ","code_information":[{"code":"309","type":"RC"},{"code":"82373","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.71,"maximum":70.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":69.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.43,"methodology":"fee schedule"}]}]},{"description":"Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; ","code_information":[{"code":"58953","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50- 100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psor ","code_information":[{"code":"0258U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6045.38,"maximum":14332.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6045.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14126.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6717.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6717.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14332.50,"methodology":"fee schedule"}]}]},{"description":"Enucleation of eye; with implant, muscles not attached to implant ","code_information":[{"code":"65103","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging ","code_information":[{"code":"324","type":"RC"},{"code":"75563","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":701.35,"maximum":779.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":701.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":773.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":779.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":779.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":773.67,"methodology":"fee schedule"}]}]},{"description":"1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization of urethra ","code_information":[{"code":"369","type":"RC"},{"code":"54326","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm ","code_information":[{"code":"25075","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (eg, pre-transplant recipient and donor germline testing, post-transplant non-hematopoietic recipient ger ","code_information":[{"code":"306","type":"RC"},{"code":"81265","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":383.40,"maximum":908.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":383.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":895.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":426.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":426.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":908.97,"methodology":"fee schedule"}]}]},{"description":"Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions ","code_information":[{"code":"11056","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral ","code_information":[{"code":"22511","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8240.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17303.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9155.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9155.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17303.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Injection, thiethylperazine maleate, up to 10 mg ","code_information":[{"code":"J3280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.26,"maximum":12.77,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":12.77,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":12.77,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":5.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":6.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":5.26,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":6.58,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; toe(s), minimum of 2 views ","code_information":[{"code":"324","type":"RC"},{"code":"73660","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":31.92,"maximum":35.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":35.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35.21,"methodology":"fee schedule"}]}]},{"description":"Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass ","code_information":[{"code":"33720","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Removal, implantable contraceptive capsules ","code_information":[{"code":"11976","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC ","code_information":[{"code":"097","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"087","type":"MS-DRG"},{"code":"117","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":1336.39,"maximum":1336.39,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1336.39,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve ","code_information":[{"code":"369","type":"RC"},{"code":"42420","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"138","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Plastic repair of salivary duct, sialodochoplasty; secondary or complicated ","code_information":[{"code":"361","type":"RC"},{"code":"42505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Antibody; Candida ","code_information":[{"code":"304","type":"RC"},{"code":"86628","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.76,"maximum":46.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.84,"methodology":"fee schedule"}]}]},{"description":"GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence ","code_information":[{"code":"302","type":"RC"},{"code":"81252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":166.34,"maximum":394.37,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":166.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":388.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":184.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":184.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":394.37,"methodology":"fee schedule"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach ","code_information":[{"code":"369","type":"RC"},{"code":"63305","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75807","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":259.98,"maximum":288.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":259.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":286.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":288.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":288.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":286.79,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC ","code_information":[{"code":"148","type":"RC"},{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of transvenous pacemaker electrode(s); dual lead system ","code_information":[{"code":"33235","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only ","code_information":[{"code":"33280","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC ","code_information":[{"code":"803","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11845.43,"maximum":11967.54,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":11845.43,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":11967.54,"methodology":"fee schedule"}]}]},{"description":"Hepatitis c antibody screening, for individual at high risk and other covered indication(s) ","code_information":[{"code":"304","type":"RC"},{"code":"G0472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":76.25,"maximum":180.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":76.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":178.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":84.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":84.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":180.77,"methodology":"fee schedule"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC ","code_information":[{"code":"070","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SEPTIC ARTHRITIS WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length ","code_information":[{"code":"369","type":"RC"},{"code":"54112","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic a3cid, genitourinary pathogen, semiquantitative identification, DNA from 16 bacterial organisms and 1 fungal organism, multiplex amplified probe technique via qua ","code_information":[{"code":"0371U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"27893","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Scleral reinforcement (separate procedure); with graft ","code_information":[{"code":"490","type":"RC"},{"code":"67255","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES ","code_information":[{"code":"142","type":"RC"},{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair of nonunion or malunion, tibia; by synostosis, with fibula, any method ","code_information":[{"code":"27725","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) ","code_information":[{"code":"81328","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":139.85,"maximum":744.50,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":178.31,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":305.55,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":744.50,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":744.27,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":178.31,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":178.31,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":510.25,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":579.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":463.88,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":579.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":444.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":139.85,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":181.80,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":175.68,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":174.81,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":181.80,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire ","code_information":[{"code":"43196","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Excision of rectal procidentia, with anastomosis; abdominal and perineal approach ","code_information":[{"code":"45135","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC ","code_information":[{"code":"059","type":"MS-DRG"},{"code":"204","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Urea nitrogen; quantitative ","code_information":[{"code":"309","type":"RC"},{"code":"84520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6.50,"maximum":15.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":15.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15.41,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation ","code_information":[{"code":"27824","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Decompressive fasciotomy, hand (excludes 26035) ","code_information":[{"code":"26037","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) ","code_information":[{"code":"340","type":"RC"},{"code":"78122","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":516.11,"maximum":573.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":516.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":569.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":573.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":573.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":569.32,"methodology":"fee schedule"}]}]},{"description":"Tracheostoma filter, any type, any size, each ","code_information":[{"code":"A4481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.40,"maximum":0.87,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":0.51,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":0.87,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":0.51,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":0.51,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":0.50,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.48,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":0.40,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":0.52,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.49,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":0.50,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":0.50,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":0.50,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":0.52,"methodology":"fee schedule"}]}]},{"description":"Phosphatase, alkaline; heat stable (total not included) ","code_information":[{"code":"309","type":"RC"},{"code":"84078","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.59,"maximum":32.21,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":31.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":15.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":15.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":32.21,"methodology":"fee schedule"}]}]},{"description":"Injection of sinus tract; diagnostic (sinogram) ","code_information":[{"code":"20501","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Cranioplasty for skull defect with reparative brain surgery ","code_information":[{"code":"490","type":"RC"},{"code":"62145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"304","type":"RC"},{"code":"81178","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar ","code_information":[{"code":"499","type":"RC"},{"code":"63252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft) ","code_information":[{"code":"24346","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":28614.00,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ureteroplasty, plastic operation on ureter (eg, stricture) ","code_information":[{"code":"369","type":"RC"},{"code":"50700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Chromosome analysis; additional karyotypes, each study ","code_information":[{"code":"310","type":"RC"},{"code":"88280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.06,"maximum":130.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":128.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":61.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":61.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":130.53,"methodology":"fee schedule"}]}]},{"description":"Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less ","code_information":[{"code":"14020","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Incision and drainage, leg or ankle; deep abscess or hematoma ","code_information":[{"code":"27603","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed ","code_information":[{"code":"0481T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revision or removal of percutaneously placed integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator, including analysis, pro ","code_information":[{"code":"0588T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contras ","code_information":[{"code":"360","type":"RC"},{"code":"C7513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Antibody; encephalitis, Eastern equine ","code_information":[{"code":"301","type":"RC"},{"code":"86652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.70,"maximum":51.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.44,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique ","code_information":[{"code":"300","type":"RC"},{"code":"87555","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.22,"maximum":104.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":103.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":49.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":49.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":104.83,"methodology":"fee schedule"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC ","code_information":[{"code":"142","type":"RC"},{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less ","code_information":[{"code":"11640","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Total facial nerve decompression and/or repair (may include graft) ","code_information":[{"code":"69955","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Antibody; tetanus ","code_information":[{"code":"302","type":"RC"},{"code":"86774","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.35,"maximum":57.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":56.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":57.72,"methodology":"fee schedule"}]}]},{"description":"Removal of implant from finger or hand ","code_information":[{"code":"26320","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Radiologic examination, chest; 4 or more views ","code_information":[{"code":"71048","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":120.15,"maximum":498.23,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":498.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":498.23,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":132.16,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":150.19,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":120.15,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":150.19,"methodology":"fee schedule"}]}]},{"description":"Cryopreservation, mature oocyte(s) ","code_information":[{"code":"304","type":"RC"},{"code":"89337","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation ","code_information":[{"code":"77054","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":185.35,"maximum":1088.58,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1088.58,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1088.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":203.88,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":231.68,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":185.35,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":231.68,"methodology":"fee schedule"}]}]},{"description":"MR safety determination by a physician or other qualified health care professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examinatio ","code_information":[{"code":"323","type":"RC"},{"code":"76016","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":378.82,"maximum":420.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":378.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":417.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":420.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":420.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":417.88,"methodology":"fee schedule"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"124","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":994.34,"maximum":1014.23,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1014.23,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":994.34,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture) ","code_information":[{"code":"20527","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"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":"322","type":"RC"},{"code":"77767","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1305.66,"maximum":1450.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1305.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1440.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1450.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1450.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1440.29,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA/RNA), vaginal pathogen panel, identification of 27 organisms, amplified probe technique, vaginal swab ","code_information":[{"code":"0330U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"58100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Esophagoscopy, flexible, transoral, with initial transendoscopic mechanical dilation (eg, nondrug-coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for esophageal s ","code_information":[{"code":"0884T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal of embedded foreign body, vestibule of mouth; complicated ","code_information":[{"code":"40805","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Removal of transplanted intestinal allograft, complete ","code_information":[{"code":"44137","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITH CC ","code_information":[{"code":"207","type":"RC"},{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) ","code_information":[{"code":"499","type":"RC"},{"code":"54160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"141","type":"RC"},{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"200","type":"RC"},{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination; neck, soft tissue ","code_information":[{"code":"320","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":118.68,"maximum":131.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":118.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":130.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":131.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":131.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":130.92,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"688","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy, flexible; with removal of lesion(s), non-laser ","code_information":[{"code":"31578","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHE ","code_information":[{"code":"125","type":"RC"},{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor ","code_information":[{"code":"499","type":"RC"},{"code":"60545","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) ","code_information":[{"code":"64449","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Mastoidectomy; radical ","code_information":[{"code":"69511","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC ","code_information":[{"code":"499","type":"RC"},{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Percutaneous pulmonary artery revascularization by stent placement, initial; abnormal connections, unilateral ","code_information":[{"code":"33902","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Radiologic examination, pharynx and/or cervical esophagus, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study ","code_information":[{"code":"329","type":"RC"},{"code":"74210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":480.80,"maximum":534.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":480.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":530.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":534.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":534.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":530.37,"methodology":"fee schedule"}]}]},{"description":"Excision soft tissue lesion, external auditory canal ","code_information":[{"code":"69145","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Cholecystoenterostomy; Roux-en-Y ","code_information":[{"code":"47740","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cast supplies, long leg splint, pediatric (0-10 years), fiberglass ","code_information":[{"code":"Q4044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":17.08,"maximum":37.32,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":21.78,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":37.32,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":21.78,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":21.78,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":21.35,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":20.71,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":17.08,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":22.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":20.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21.46,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":21.35,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":21.35,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":22.20,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"116","type":"RC"},{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Rare diseases (constitutional/heritable disorders), whole mitochordrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochrondrial gene analysis of 335 nuclear g ","code_information":[{"code":"0417U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4675.96,"maximum":11085.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4675.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10926.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5196.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5196.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":11085.87,"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"}],"standard_charges":[{"setting":"outpatient","minimum":56.16,"maximum":122.70,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":71.60,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":122.70,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":71.60,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":71.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":70.20,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":56.16,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":73.01,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":70.55,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":70.20,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":70.20,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":73.01,"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":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"214","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS ","code_information":[{"code":"065","type":"MS-DRG"},{"code":"121","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Inherited bone marrow failure syndromes (IBMFS) (eg, Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, congenital amegakaryocytic ","code_information":[{"code":"81441","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1958.85,"maximum":10427.90,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":2181.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2497.53,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":4279.84,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":10427.90,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":10424.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2497.53,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2497.53,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":7147.10,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":8121.63,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":6497.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":8121.63,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":6225.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":2448.56,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1958.85,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2546.50,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2460.80,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":2448.56,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":2448.56,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":2245.08,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":2546.50,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe ","code_information":[{"code":"31660","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC ","code_information":[{"code":"160","type":"RC"},{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) ","code_information":[{"code":"300","type":"RC"},{"code":"87040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.98,"maximum":40.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40.25,"methodology":"fee schedule"}]}]},{"description":"Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0278U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1000.44,"maximum":2371.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1000.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2337.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2371.86,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family ","code_information":[{"code":"36217","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Sugars (mono-, di-, and oligosaccharides); single quantitative, each specimen ","code_information":[{"code":"303","type":"RC"},{"code":"84378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.97,"maximum":44.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":44.97,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft) ","code_information":[{"code":"26541","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Octreotide injection, depo ","code_information":[{"code":"01207","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":197.48,"maximum":199.51,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":197.48,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":199.51,"methodology":"fee schedule"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  IPF","code_information":[{"code":"126","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1143.49,"maximum":1143.49,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1143.49,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"Sedimentation rate, erythrocyte; non-automated ","code_information":[{"code":"85651","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7.02,"maximum":16.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.65,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter) ","code_information":[{"code":"43220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2000.00,"maximum":2000.00,"payers_information":[{"payer_name":"MVP Health Plan","plan_name":"COMM","standard_charge_dollar":2000.00,"methodology":"case rate"}]}]},{"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":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, wrist; 2 views ","code_information":[{"code":"400","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":134.41,"maximum":149.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":134.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":148.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":149.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":149.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":148.27,"methodology":"fee schedule"}]}]},{"description":"Plastic repair of canaliculi ","code_information":[{"code":"499","type":"RC"},{"code":"68700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"75726","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":874.26,"maximum":971.21,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":874.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":964.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":971.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":971.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":964.41,"methodology":"fee schedule"}]}]},{"description":"MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"301","type":"RC"},{"code":"81304","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":246.75,"maximum":585.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":246.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":576.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":274.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":274.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":585.00,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial ","code_information":[{"code":"29895","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Application of body cast, shoulder to hips; ","code_information":[{"code":"29035","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection, gonadorelin hydrochloride, per 100 mcg ","code_information":[{"code":"J1620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":199.34,"maximum":249.17,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":219.30,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":249.17,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":199.34,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":249.17,"methodology":"fee schedule"}]}]},{"description":"Application of Risser jacket, localizer, body; only ","code_information":[{"code":"29010","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hepaticotomy or hepaticostomy with exploration, drainage, or removal of calculus ","code_information":[{"code":"369","type":"RC"},{"code":"47400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MAJOR MALE PELVIC PROCEDURES WITH CC/MCC ","code_information":[{"code":"360","type":"RC"},{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair, congenital arteriovenous fistula; head and neck ","code_information":[{"code":"35180","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis ","code_information":[{"code":"81302","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":868.35,"maximum":2058.69,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":868.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2029.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":964.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":964.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2058.69,"methodology":"fee schedule"}]}]},{"description":"Thoracostomy; with open flap drainage for empyema ","code_information":[{"code":"32036","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic ","code_information":[{"code":"360","type":"RC"},{"code":"63286","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Perineoplasty, repair of perineum, nonobstetrical (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"56810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in addition to code for nerve suture) ","code_information":[{"code":"64874","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision of hydrocele; unilateral ","code_information":[{"code":"360","type":"RC"},{"code":"55040","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC  IPF","code_information":[{"code":"056","type":"MS-DRG"},{"code":"126","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1135.93,"maximum":1135.93,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1135.93,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical n ","code_information":[{"code":"490","type":"RC"},{"code":"51800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC ","code_information":[{"code":"360","type":"RC"},{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"303","type":"RC"},{"code":"81297","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":350.88,"maximum":831.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":350.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":819.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":389.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":389.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":831.87,"methodology":"fee schedule"}]}]},{"description":"Percutaneous balloon valvuloplasty; pulmonary valve ","code_information":[{"code":"499","type":"RC"},{"code":"92990","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5749.00,"maximum":14872.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5749.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10149.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6388.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6388.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":10149.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":14872.70,"methodology":"case rate"}]}]},{"description":"Addition to lower extremity, symes type, medial opening socket ","code_information":[{"code":"L5636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":326.21,"maximum":712.72,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":415.92,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":712.72,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":415.92,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":415.92,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":407.76,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":395.53,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":326.21,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":424.07,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":399.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":409.80,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":407.76,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":407.76,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":424.07,"methodology":"fee schedule"}]}]},{"description":"Oncology (pan-cancer), analysis of MRD from plasma, with assays personalized to each patient based on prior next generation sequencing of the patient's tumor and germline DNA, reported as absence or p ","code_information":[{"code":"0340U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6448.40,"maximum":15288.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6448.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":15068.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7165.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7165.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15288.00,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0269U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1000.44,"maximum":2371.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1000.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2337.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2371.86,"methodology":"fee schedule"}]}]},{"description":"Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using ","code_information":[{"code":"310","type":"RC"},{"code":"88361","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":479.12,"maximum":1135.91,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":479.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1119.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":532.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":532.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1135.91,"methodology":"fee schedule"}]}]},{"description":"Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) ","code_information":[{"code":"67908","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19023.00,"maximum":22929.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"202","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Congo red, blood ","code_information":[{"code":"923","type":"RC"},{"code":"P2029","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.14,"maximum":19.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.30,"methodology":"fee schedule"}]}]},{"description":"Homovanillic acid (HVA) ","code_information":[{"code":"300","type":"RC"},{"code":"83150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":36.86,"maximum":87.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":86.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":87.40,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"126","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":966.50,"maximum":966.50,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":966.50,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach ","code_information":[{"code":"58140","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision of malignant tumor of mandible; ","code_information":[{"code":"21044","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Transection or avulsion of; facial nerve, differential or complete ","code_information":[{"code":"64742","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Repair of ectropion; thermocauterization ","code_information":[{"code":"67915","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine; thoracic, minimum of 4 views ","code_information":[{"code":"329","type":"RC"},{"code":"72074","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":172.96,"maximum":192.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":172.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":190.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":192.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":192.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":190.80,"methodology":"fee schedule"}]}]},{"description":"Inj brixadi, more than 7 d ","code_information":[{"code":"733","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1346.04,"maximum":2940.92,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1716.20,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2940.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1716.20,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1716.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1682.55,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1346.04,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1749.85,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1690.96,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1682.55,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1682.55,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1749.85,"methodology":"fee schedule"}]}]},{"description":"Organic acids; total, quantitative, each specimen ","code_information":[{"code":"83918","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":38.82,"maximum":92.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":38.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":90.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":43.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":43.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":92.04,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"133","type":"RC"},{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique ","code_information":[{"code":"309","type":"RC"},{"code":"87532","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"27499","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) ","code_information":[{"code":"J0882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.83,"maximum":7.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":3.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5.48,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":7.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7.97,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":3.61,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4.10,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3.28,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4.10,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2.83,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2.86,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse technique, when performed) ","code_information":[{"code":"22612","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11152.90,"maximum":83200.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":54000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":60000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":60000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification ","code_information":[{"code":"304","type":"RC"},{"code":"87652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":68.70,"maximum":162.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":68.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":160.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":76.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":76.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":162.86,"methodology":"fee schedule"}]}]},{"description":"Organic acid, single, quantitative ","code_information":[{"code":"304","type":"RC"},{"code":"83921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.89,"maximum":82.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":81.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":82.72,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, hemic or lymphatic system ","code_information":[{"code":"369","type":"RC"},{"code":"38999","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Transcortin (cortisol binding globulin) ","code_information":[{"code":"84449","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29.61,"maximum":70.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":69.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.20,"methodology":"fee schedule"}]}]},{"description":"Bone marrow, smear interpretation ","code_information":[{"code":"307","type":"RC"},{"code":"85097","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1079.37,"maximum":2558.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1079.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2522.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2558.98,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC ","code_information":[{"code":"101","type":"RC"},{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"74300","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":65.48,"maximum":72.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":65.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":72.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":72.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":72.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":72.24,"methodology":"fee schedule"}]}]},{"description":"Appendectomy; ","code_information":[{"code":"44950","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC ","code_information":[{"code":"025","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) ","code_information":[{"code":"36012","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Triiodothyronine T3; free ","code_information":[{"code":"301","type":"RC"},{"code":"37775","type":"CDM"},{"code":"84481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.87,"maximum":66.07,"gross_charge":590.25,"discounted_cash":590.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":65.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":66.07,"methodology":"fee schedule"}]}]},{"description":"Suture of tracheal wound or injury; intrathoracic ","code_information":[{"code":"31805","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Treprostinil injection ","code_information":[{"code":"01701","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":53.07,"maximum":53.61,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":53.07,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":53.61,"methodology":"fee schedule"}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"125","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants ","code_information":[{"code":"302","type":"RC"},{"code":"81221","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":159.93,"maximum":379.16,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":159.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":373.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":177.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":177.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":379.16,"methodology":"fee schedule"}]}]},{"description":"Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival ","code_information":[{"code":"301","type":"RC"},{"code":"81538","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4722.80,"maximum":11196.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4722.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":11036.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5248.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5248.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":11196.90,"methodology":"fee schedule"}]}]},{"description":"Excision of extraparenchymal lesion of testis ","code_information":[{"code":"499","type":"RC"},{"code":"54512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) ","code_information":[{"code":"303","type":"RC"},{"code":"81237","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":288.53,"maximum":684.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":288.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":674.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":320.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":320.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":684.06,"methodology":"fee schedule"}]}]},{"description":"Gastric restrictive procedure, open; revision of subcutaneous port component only ","code_information":[{"code":"369","type":"RC"},{"code":"43886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"118","type":"RC"},{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately in addition to code for primary procedure) ","code_information":[{"code":"22614","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy) ","code_information":[{"code":"499","type":"RC"},{"code":"61576","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Bone marrow harvesting for transplantation; allogeneic ","code_information":[{"code":"369","type":"RC"},{"code":"38230","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition ","code_information":[{"code":"19286","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators ","code_information":[{"code":"400","type":"RC"},{"code":"77610","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":3171.79,"maximum":3523.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3171.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3498.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3523.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3523.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3498.84,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Treponema pallidum ","code_information":[{"code":"309","type":"RC"},{"code":"87285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.04,"maximum":47.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47.50,"methodology":"fee schedule"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock ","code_information":[{"code":"15835","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, cervical; 6 or more views ","code_information":[{"code":"324","type":"RC"},{"code":"72052","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":72.27,"maximum":80.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":72.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":79.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":80.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":80.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":79.72,"methodology":"fee schedule"}]}]},{"description":"Syndactylization, toes (eg, webbing or Kelikian type procedure) ","code_information":[{"code":"28280","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region ","code_information":[{"code":"31291","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Pollicization of a digit ","code_information":[{"code":"26550","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PULMONARY EMBOLISM WITHOUT MCC ","code_information":[{"code":"176","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"134","type":"RC"},{"code":"148","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION  IPF","code_information":[{"code":"124","type":"RC"},{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1263.40,"maximum":1288.66,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1288.66,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1263.40,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT ","code_information":[{"code":"101","type":"RC"},{"code":"124","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"143","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"303","type":"RC"},{"code":"87154","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":358.71,"maximum":850.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":358.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":838.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":398.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":398.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":850.43,"methodology":"fee schedule"}]}]},{"description":"Anterior tibial tubercleplasty (eg, Maquet type procedure) ","code_information":[{"code":"27418","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Inj enfort vedo-ejfv 0.25m ","code_information":[{"code":"9364","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":29.39,"maximum":64.22,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":37.48,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":64.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":37.48,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":37.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":36.74,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":29.39,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":38.21,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":36.93,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":36.74,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":36.74,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":38.21,"methodology":"fee schedule"}]}]},{"description":"Novafix dl, per square centimeter ","code_information":[{"code":"Q4254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":393.46,"maximum":1094.26,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1094.26,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1094.26,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":432.86,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":491.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":393.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":491.83,"methodology":"fee schedule"}]}]},{"description":"Intracavitary radiation source application; complex ","code_information":[{"code":"329","type":"RC"},{"code":"77763","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":1768.62,"maximum":1964.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1768.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1950.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1964.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1964.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1950.99,"methodology":"fee schedule"}]}]},{"description":"Triiodothyronine T3; reverse ","code_information":[{"code":"305","type":"RC"},{"code":"84482","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.93,"maximum":61.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":60.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.46,"methodology":"fee schedule"}]}]},{"description":"POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES ","code_information":[{"code":"155","type":"RC"},{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach; ","code_information":[{"code":"46746","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery) ","code_information":[{"code":"67825","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Antibody; JC (John Cunningham) virus ","code_information":[{"code":"304","type":"RC"},{"code":"86711","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.78,"maximum":65.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.87,"methodology":"fee schedule"}]}]},{"description":"Metanephrines ","code_information":[{"code":"83835","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.87,"maximum":66.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":65.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":66.07,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) ","code_information":[{"code":"25520","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Orthopedic shoe addition, toe tap, horseshoe ","code_information":[{"code":"L3560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21.55,"maximum":47.09,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":27.48,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":47.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":27.48,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":27.48,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":26.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":26.13,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":21.55,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":28.02,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":26.40,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":27.07,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":26.94,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":26.94,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":28.02,"methodology":"fee schedule"}]}]},{"description":"Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon ","code_information":[{"code":"26480","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"204","type":"RC"},{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; ","code_information":[{"code":"400","type":"RC"},{"code":"75561","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":1282.17,"maximum":1424.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1282.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1414.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1424.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1424.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1414.38,"methodology":"fee schedule"}]}]},{"description":"Removal of wrist prosthesis; complicated, including total wrist ","code_information":[{"code":"25251","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Insertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse ","code_information":[{"code":"0916T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MSH6 (mutS homolog 6 ºE. coli») (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants ","code_information":[{"code":"81299","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":506.66,"maximum":1201.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":506.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1183.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":563.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":563.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1201.20,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed ","code_information":[{"code":"64415","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transection or avulsion of other spinal nerve, extradural ","code_information":[{"code":"361","type":"RC"},{"code":"64772","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps ","code_information":[{"code":"61001","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Drainage external auditory canal, abscess ","code_information":[{"code":"361","type":"RC"},{"code":"69020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening ","code_information":[{"code":"307","type":"RC"},{"code":"G0148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":52.54,"maximum":124.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":52.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":122.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":58.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":58.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":124.57,"methodology":"fee schedule"}]}]},{"description":"Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies ","code_information":[{"code":"361","type":"RC"},{"code":"45121","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"149","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance ","code_information":[{"code":"49083","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"208","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Pericardiectomy, subtotal or complete; with cardiopulmonary bypass ","code_information":[{"code":"33031","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Dilation of urethral stricture by passage of sound or urethral dilator, male; initial ","code_information":[{"code":"481","type":"RC"},{"code":"53600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Chromium cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries ","code_information":[{"code":"A9553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.01,"maximum":952.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.02,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":952.08,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":952.08,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":699.71,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":795.04,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":636.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":795.04,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) ","code_information":[{"code":"65678","type":"CDM"},{"code":"71551","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1163.22,"maximum":1454.04,"gross_charge":8430.75,"discounted_cash":8430.75,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1279.54,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1454.04,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1163.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1454.04,"methodology":"fee schedule"}]}]},{"description":"Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic ","code_information":[{"code":"22510","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8240.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17303.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9155.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9155.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17303.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, ","code_information":[{"code":"0070U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1112.63,"maximum":2637.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1112.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2599.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1236.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1236.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2637.84,"methodology":"fee schedule"}]}]},{"description":"Revision of sub-scalp implanted electrode array, receiver, and telemetry unit for electrode, when required, including imaging guidance ","code_information":[{"code":"0957T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"212","type":"RC"},{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"46924","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Glucose; post glucose dose (includes glucose) ","code_information":[{"code":"304","type":"RC"},{"code":"82950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.81,"maximum":18.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":18.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18.52,"methodology":"fee schedule"}]}]},{"description":"Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic ","code_information":[{"code":"63055","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"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":"63012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40275.00,"maximum":48081.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":40275.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":48081.00,"methodology":"case rate"}]}]},{"description":"Osteoplasty, lengthening, metacarpal or phalanx ","code_information":[{"code":"26568","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Sympathectomy; superficial palmar arch ","code_information":[{"code":"369","type":"RC"},{"code":"64823","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Drainage of lymph node abscess or lymphadenitis; extensive ","code_information":[{"code":"38305","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Radiologic examination; sternoclavicular joint or joints, minimum of 3 views ","code_information":[{"code":"321","type":"RC"},{"code":"71130","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":160.68,"maximum":178.49,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":160.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":177.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":178.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":178.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":177.24,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"1-stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap ","code_information":[{"code":"54328","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, diagnostic (separate procedure); mediastinal space, with biopsy ","code_information":[{"code":"32606","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of po ","code_information":[{"code":"33224","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Closure of ureterovisceral fistula (including visceral repair) ","code_information":[{"code":"361","type":"RC"},{"code":"50930","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed ","code_information":[{"code":"0908T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) ","code_information":[{"code":"15840","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination; scapula, complete ","code_information":[{"code":"409","type":"RC"},{"code":"73010","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.90,"maximum":48.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":43.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":48.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":48.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":48.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.42,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (colton blood group) genotyping (CO), gene analysis, AQP1 (aquaporin 1) exon 1 ","code_information":[{"code":"0181U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC ","code_information":[{"code":"056","type":"MS-DRG"},{"code":"149","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Capsulodesis, metacarpophalangeal joint; single digit ","code_information":[{"code":"26516","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"115","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of distal radioulnar dislocation with manipulation ","code_information":[{"code":"25675","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Suture repair of aorta or great vessels; with cardiopulmonary bypass ","code_information":[{"code":"33322","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"146","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"81407","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1392.11,"maximum":3300.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1392.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3253.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1546.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1546.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3300.45,"methodology":"fee schedule"}]}]},{"description":"Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length ","code_information":[{"code":"360","type":"RC"},{"code":"64893","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"NON-EXTENSIVE BURNS ","code_information":[{"code":"151","type":"RC"},{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic ","code_information":[{"code":"0220T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"128","type":"RC"},{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, nasal polyp(s), simple ","code_information":[{"code":"30110","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Orchiectomy, partial ","code_information":[{"code":"490","type":"RC"},{"code":"54522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Removal of a total replacement heart system (artificial heart) for heart transplantation (List separately in addition to code for primary procedure) ","code_information":[{"code":"33929","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1114.54,"maximum":1136.83,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1136.83,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1114.54,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Amnioexcel, amnioexcel plus or biodexcel, per square centimeter ","code_information":[{"code":"Q4137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":99.11,"maximum":312.94,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":312.94,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":312.94,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":141.92,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":161.25,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":129.00,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":161.25,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":99.11,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":100.14,"methodology":"fee schedule"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITH CC/MCC ","code_information":[{"code":"121","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Insertion of implantable defibrillator pulse generator only; with existing single lead ","code_information":[{"code":"33240","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34061.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37708.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":37844.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":37844.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37708.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Lead ","code_information":[{"code":"306","type":"RC"},{"code":"83655","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.92,"maximum":47.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47.23,"methodology":"fee schedule"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"114","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1351.13,"maximum":1378.15,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1378.15,"methodology":"fee schedule","additional_payer_notes":"Days 1. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1351.13,"methodology":"fee schedule","additional_payer_notes":"Days 1. "}]}]},{"description":"Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent ","code_information":[{"code":"490","type":"RC"},{"code":"68815","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"204","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Gradient compression stocking, thigh length, 18-30 mmhg, each ","code_information":[{"code":"A6533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":42.74,"maximum":93.37,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":54.49,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":93.37,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":54.49,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":54.49,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":53.42,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":51.82,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":42.74,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":55.56,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":52.35,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":53.69,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":53.42,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":53.42,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":55.56,"methodology":"fee schedule"}]}]},{"description":"HYPERTENSION WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, sacral pressure ulcer, with skin flap closure; ","code_information":[{"code":"15934","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy) ","code_information":[{"code":"32669","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, wrist, arthrography, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"73115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":682.13,"maximum":757.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":682.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":752.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":757.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":757.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":752.47,"methodology":"fee schedule"}]}]},{"description":"Glucose; blood, reagent strip ","code_information":[{"code":"82948","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.29,"maximum":19.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.66,"methodology":"fee schedule"}]}]},{"description":"Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical ","code_information":[{"code":"63270","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Therapeutic radiology simulation-aided field setting; complex ","code_information":[{"code":"321","type":"RC"},{"code":"77290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2299.43,"maximum":2554.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2299.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2536.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2554.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2554.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2536.53,"methodology":"fee schedule"}]}]},{"description":"APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis ºFAP», attenuated FAP) gene analysis; duplication/deletion variants ","code_information":[{"code":"300","type":"RC"},{"code":"81203","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":329.00,"maximum":780.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":329.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":768.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":365.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":365.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":780.00,"methodology":"fee schedule"}]}]},{"description":"Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches ","code_information":[{"code":"E2204","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":671.46,"maximum":1467.06,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":856.12,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1467.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":856.12,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":856.12,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":839.33,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":814.15,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":671.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":872.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":822.54,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":843.53,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":839.33,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":839.33,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":872.90,"methodology":"fee schedule"}]}]},{"description":"ACTH stimulation panel; for adrenal insufficiency This panel must include the following: Cortisol (82533 x 2) ","code_information":[{"code":"307","type":"RC"},{"code":"80400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":53.66,"maximum":127.22,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":53.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":125.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":59.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":59.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":127.22,"methodology":"fee schedule"}]}]},{"description":"Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff ","code_information":[{"code":"53445","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9905.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17487.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11006.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11006.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17487.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC ","code_information":[{"code":"086","type":"MS-DRG"},{"code":"125","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separa ","code_information":[{"code":"33367","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma ","code_information":[{"code":"0055U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5329.80,"maximum":12636.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5329.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":12454.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12636.00,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; sternum, minimum of 2 views ","code_information":[{"code":"320","type":"RC"},{"code":"71120","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":125.67,"maximum":139.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":125.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":138.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":139.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":139.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":138.63,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays ","code_information":[{"code":"361","type":"RC"},{"code":"61886","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":63632.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36318.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Revision of ileostomy; simple (release of superficial scar) (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"44312","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"66630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic ","code_information":[{"code":"22212","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST TRAUMA WITH CC ","code_information":[{"code":"131","type":"RC"},{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Coronary artery bypass, vein only; 5 coronary venous grafts ","code_information":[{"code":"33514","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver ","code_information":[{"code":"369","type":"RC"},{"code":"63685","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":63632.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36318.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) ","code_information":[{"code":"305","type":"RC"},{"code":"89060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.06,"maximum":28.59,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.59,"methodology":"fee schedule"}]}]},{"description":"Lateral retinacular release, open ","code_information":[{"code":"27425","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"143","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Therapeutic drug monitoring, 80 or more psychoactive drugs or substances, LC-MS/MS, plasma, qualitative and quantitative therapeutic minimally and maximally effective dose of prescribed and non-prescr ","code_information":[{"code":"0517U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":406.18,"maximum":962.99,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":406.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":949.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":451.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":451.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":962.99,"methodology":"fee schedule"}]}]},{"description":"Nerve repair; with nerve allograft, each additional strand (List separately in addition to code for primary procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"64913","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia ","code_information":[{"code":"481","type":"RC"},{"code":"53605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants ","code_information":[{"code":"58565","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Morphometric analysis; tumor (eg, DNA ploidy) ","code_information":[{"code":"314","type":"RC"},{"code":"88358","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; sternoclavicular joint or joints, minimum of 3 views ","code_information":[{"code":"329","type":"RC"},{"code":"71130","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":212.95,"maximum":236.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":212.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":234.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":236.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":236.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":234.91,"methodology":"fee schedule"}]}]},{"description":"Impression and custom preparation; oral surgical splint ","code_information":[{"code":"21085","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision, unilateral ","code_information":[{"code":"33889","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, sin ","code_information":[{"code":"33806","type":"CDM"},{"code":"341","type":"RC"},{"code":"78802","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1435.34,"maximum":1594.52,"gross_charge":8478.50,"discounted_cash":8478.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1435.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1583.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1594.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1594.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1583.35,"methodology":"fee schedule"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"167","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only ","code_information":[{"code":"33279","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"304","type":"RC"},{"code":"87320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.68,"maximum":58.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.50,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy, flexible; with removal of foreign body(s) ","code_information":[{"code":"45379","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"SEIZURES WITHOUT MCC ","code_information":[{"code":"101","type":"MS-DRG"},{"code":"115","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf ","code_information":[{"code":"L3650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":64.82,"maximum":141.63,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":82.65,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":141.63,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":82.65,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":82.65,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":81.03,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":78.60,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":64.82,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":84.27,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":79.41,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":81.44,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":81.03,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":81.03,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":84.27,"methodology":"fee schedule"}]}]},{"description":"Autologous blood or component, collection processing and storage; predeposited ","code_information":[{"code":"305","type":"RC"},{"code":"86890","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Phenytoin; free ","code_information":[{"code":"300","type":"RC"},{"code":"80186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.64,"maximum":53.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.66,"methodology":"fee schedule"}]}]},{"description":"Oncology (Multiple myloma),liquid chromatography with tandem mass spectrometry (LCMS/MS),monoclonal paraprotein sequencing analysis,serum,results reported as baseline presence or absence of detectable ","code_information":[{"code":"0450U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":71.44,"maximum":169.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":71.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":166.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":79.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":79.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":169.38,"methodology":"fee schedule"}]}]},{"description":"Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach ","code_information":[{"code":"481","type":"RC"},{"code":"66183","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":12033.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Blood bank physician services; investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report ","code_information":[{"code":"305","type":"RC"},{"code":"86078","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC ","code_information":[{"code":"059","type":"MS-DRG"},{"code":"169","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"COMPLICATIONS OF TREATMENT WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"VIRAL ILLNESS WITH MCC ","code_information":[{"code":"155","type":"RC"},{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"211","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing at least 20 molecular features, saliva, algorithm reported as positive or negative for signature associated wit ","code_information":[{"code":"0296U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2886.97,"maximum":6844.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2886.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6746.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6844.50,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Orthopoxvirus (eg, monkeypox virus, cowpox virus, vaccinia virus), amplified probe technique, each ","code_information":[{"code":"118033","type":"CDM"},{"code":"306","type":"RC"},{"code":"87593","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.17,"maximum":199.56,"gross_charge":105.75,"discounted_cash":105.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":196.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":93.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":93.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":199.56,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE ","code_information":[{"code":"158","type":"RC"},{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm ","code_information":[{"code":"12036","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Lso, full corset ","code_information":[{"code":"L0976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":154.05,"maximum":336.58,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":196.41,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":336.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":196.41,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":196.41,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":192.56,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":186.78,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":154.05,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":200.26,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":188.71,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":193.52,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":192.56,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":192.56,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":200.26,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar ","code_information":[{"code":"321","type":"RC"},{"code":"72158","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1131.57,"maximum":1257.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1131.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1248.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1257.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1257.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1248.25,"methodology":"fee schedule"}]}]},{"description":"Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and ","code_information":[{"code":"320","type":"RC"},{"code":"77300","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":167.56,"maximum":186.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":167.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":184.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":186.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":186.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":184.84,"methodology":"fee schedule"}]}]},{"description":"Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ","code_information":[{"code":"49446","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, ","code_information":[{"code":"300","type":"RC"},{"code":"81471","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1503.53,"maximum":3564.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1503.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3513.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1670.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1670.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3564.60,"methodology":"fee schedule"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC ","code_information":[{"code":"114","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) study ","code_information":[{"code":"324","type":"RC"},{"code":"74221","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":166.59,"maximum":185.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":166.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":183.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":185.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":185.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":183.76,"methodology":"fee schedule"}]}]},{"description":"Urinalysis; qualitative or semiquantitative, except immunoassays ","code_information":[{"code":"81005","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3.57,"maximum":8.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8.46,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed ","code_information":[{"code":"361","type":"RC"},{"code":"43210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, and lower mediastinal esophagus, with separate laparoscopic proximal gastrectomy, with laparoscopic pyloric dr ","code_information":[{"code":"43288","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing ","code_information":[{"code":"22310","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC ","code_information":[{"code":"200","type":"RC"},{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service ","code_information":[{"code":"A4239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":214.34,"maximum":468.30,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":273.28,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":468.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":273.28,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":273.28,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":267.92,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":259.88,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":214.34,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":278.64,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":262.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":269.26,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":267.92,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":267.92,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":278.64,"methodology":"fee schedule"}]}]},{"description":"Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment ","code_information":[{"code":"32701","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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":"37237","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"062","type":"MS-DRG"},{"code":"137","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC ","code_information":[{"code":"120","type":"RC"},{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, lower extremity; with contrast material(s) ","code_information":[{"code":"409","type":"RC"},{"code":"73701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":876.32,"maximum":973.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":876.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":966.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":973.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":973.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":966.68,"methodology":"fee schedule"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC ","code_information":[{"code":"201","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Pyruvate kinase ","code_information":[{"code":"309","type":"RC"},{"code":"84220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.53,"maximum":36.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.82,"methodology":"fee schedule"}]}]},{"description":"Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 ºCDK1», IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score fo ","code_information":[{"code":"0013M","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.20,"maximum":2964.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2921.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2964.00,"methodology":"fee schedule"}]}]},{"description":"Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents ","code_information":[{"code":"96542","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":855.86,"maximum":855.86,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":855.86,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":855.86,"methodology":"fee schedule"}]}]},{"description":"UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT ","code_information":[{"code":"481","type":"RC"},{"code":"741","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"200","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Colonoscopy through stoma; with endoscopic mucosal resection ","code_information":[{"code":"361","type":"RC"},{"code":"44403","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score ","code_information":[{"code":"81542","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3098.40,"maximum":16494.33,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":3450.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":3950.46,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":6769.62,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16494.33,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16489.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":3950.46,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":3950.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":3873.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":3098.40,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":4027.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3892.36,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":3873.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":3873.00,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":3551.16,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":4027.92,"methodology":"fee schedule"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less ","code_information":[{"code":"17270","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Radiologic examination, teeth; single view ","code_information":[{"code":"409","type":"RC"},{"code":"70300","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":25.13,"maximum":27.92,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":27.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":27.73,"methodology":"fee schedule"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"156","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"REHABILITATION WITH CC/MCC ","code_information":[{"code":"120","type":"RC"},{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Red cell antigen (Kell blood group) genotyping (KEL), gene analysis, KEL (Kell metallo-endopeptidase) exon 8 ","code_information":[{"code":"0194U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"Sympathectomy, lumbar ","code_information":[{"code":"64818","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Brachytherapy source, non-stranded, gold-198, per source ","code_information":[{"code":"C1716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":299.52,"maximum":374.40,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":329.51,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":374.40,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":299.52,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":374.40,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC ","code_information":[{"code":"058","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":[{"setting":"outpatient","minimum":666.45,"maximum":740.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":666.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":735.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":740.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":740.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":735.17,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone ","code_information":[{"code":"69710","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"156","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1135.93,"maximum":1135.93,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1135.93,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); for exploration, with or without biopsy ","code_information":[{"code":"361","type":"RC"},{"code":"67450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"158","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D) ","code_information":[{"code":"307","type":"RC"},{"code":"81256","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":107.52,"maximum":254.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":107.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":251.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":119.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":119.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":254.90,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"45346","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; complex (eg, leaflet extension, leaflet resection, leaflet reconstruction, or annuloplasty) ","code_information":[{"code":"33391","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH MCC ","code_information":[{"code":"252","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair blood vessel, direct; hand, finger ","code_information":[{"code":"35207","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Blood count; spun microhematocrit ","code_information":[{"code":"85013","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11.52,"maximum":27.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":27.30,"methodology":"fee schedule"}]}]},{"description":"Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a bi ","code_information":[{"code":"303","type":"RC"},{"code":"81558","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5329.80,"maximum":12636.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5329.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":12454.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12636.00,"methodology":"fee schedule"}]}]},{"description":"Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfascial ","code_information":[{"code":"0819T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Oncology (diffuse large B-cell lymphoma ºDLBCL»), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of ","code_information":[{"code":"0017M","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4129.30,"maximum":9789.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4129.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9649.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4588.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4588.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9789.82,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC ","code_information":[{"code":"211","type":"RC"},{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Plastic repair of canaliculi ","code_information":[{"code":"360","type":"RC"},{"code":"68700","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach ","code_information":[{"code":"369","type":"RC"},{"code":"61546","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration ","code_information":[{"code":"0539T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Open treatment of depressed zygomatic arch fracture (eg, Gillies approach) ","code_information":[{"code":"21356","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Biopsy of tongue; posterior one-third ","code_information":[{"code":"41105","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Sigmoidoscopy, flexible; with transendoscopic balloon dilation ","code_information":[{"code":"45340","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) ","code_information":[{"code":"21151","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"RESPIRATORY NEOPLASMS WITH MCC ","code_information":[{"code":"180","type":"MS-DRG"},{"code":"208","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes ","code_information":[{"code":"97763","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.02,"maximum":89.61,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":52.30,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":89.61,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":52.30,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":52.30,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":51.27,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":49.73,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":41.02,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":53.32,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":50.24,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":51.53,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":51.27,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":51.27,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":53.32,"methodology":"fee schedule"}]}]},{"description":"Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation ","code_information":[{"code":"67210","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"HLA Class I typing, high resolution (ie, alleles or allele groups); one locus (eg, HLA-A, -B, or -C), each ","code_information":[{"code":"309","type":"RC"},{"code":"81380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":291.58,"maximum":691.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":291.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":681.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":324.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":324.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":691.27,"methodology":"fee schedule"}]}]},{"description":"Donor nephrectomy (including cold preservation); open, from living donor ","code_information":[{"code":"361","type":"RC"},{"code":"50320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"321","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":1033.91,"maximum":1148.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1033.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1140.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1148.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1148.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1140.52,"methodology":"fee schedule"}]}]},{"description":"Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each ","code_information":[{"code":"0670T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"321","type":"RC"},{"code":"76018","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":596.91,"maximum":663.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":596.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":658.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":663.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":663.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":658.46,"methodology":"fee schedule"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC ","code_information":[{"code":"206","type":"RC"},{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor ºGIST»), gene analysis, targeted sequence analysis (eg, exons 12, 18) ","code_information":[{"code":"302","type":"RC"},{"code":"81314","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":542.04,"maximum":1285.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":542.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1266.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1285.09,"methodology":"fee schedule"}]}]},{"description":"Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (eg, ","code_information":[{"code":"69637","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Proctectomy; complete, combined abdominoperineal, with colostomy ","code_information":[{"code":"45110","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Complement; functional activity, each component ","code_information":[{"code":"86161","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19.74,"maximum":46.80,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.80,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"151","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Hyoid myotomy and suspension ","code_information":[{"code":"21685","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Xylose absorption test, blood and/or urine ","code_information":[{"code":"84620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.33,"maximum":54.97,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":11.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":13.17,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":22.57,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":54.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":54.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":13.17,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":13.17,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":38.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":43.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":34.92,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":43.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":33.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":12.91,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12.95,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":10.33,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":13.43,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":13.08,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.97,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":12.91,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":12.91,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11.84,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":13.43,"methodology":"fee schedule"}]}]},{"description":"Oncology (colorectal) screening, quantitative real-time target and signal amplification of 8 RNA markers and fecal hemoglobin, algorithm reported as a positive or negative for colorectal cancer risk ","code_information":[{"code":"0421U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":837.09,"maximum":1984.59,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":837.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1956.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":930.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":930.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1984.59,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, conjunctiva ","code_information":[{"code":"499","type":"RC"},{"code":"68399","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral ","code_information":[{"code":"27392","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITH MCC ","code_information":[{"code":"202","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC ","code_information":[{"code":"146","type":"RC"},{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrotomy with meniscus repair, knee ","code_information":[{"code":"27403","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Osteotomy; radius AND ulna ","code_information":[{"code":"25365","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Myelography, cervical, radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"72240","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":217.16,"maximum":241.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":217.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":239.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":241.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":241.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":239.56,"methodology":"fee schedule"}]}]},{"description":"Russell viper venom time (includes venom); undiluted ","code_information":[{"code":"306","type":"RC"},{"code":"85612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.77,"maximum":68.21,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":67.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":68.21,"methodology":"fee schedule"}]}]},{"description":"Rhytidectomy; forehead ","code_information":[{"code":"15824","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Esophagostomy, fistulization of esophagus, external; thoracic approach ","code_information":[{"code":"43351","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Fibrin degradation products, D-dimer; qualitative or semiquantitative ","code_information":[{"code":"85378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.78,"maximum":41.41,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9.91,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":16.99,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":41.41,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":41.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9.91,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":9.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":28.37,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":32.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":25.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":32.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":24.71,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":9.75,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":7.78,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":10.11,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":9.85,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9.77,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":9.72,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":8.91,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":10.11,"methodology":"fee schedule"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC ","code_information":[{"code":"208","type":"RC"},{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oocyte identification from follicular fluid ","code_information":[{"code":"89254","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":367.98,"maximum":669.68,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":669.68,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":669.48,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":422.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":480.05,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":384.06,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":480.05,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":367.98,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial ","code_information":[{"code":"29895","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) ","code_information":[{"code":"32506","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"OSTEOMYELITIS WITHOUT CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"145","type":"RC"},{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Blood count; platelet, automated ","code_information":[{"code":"301","type":"RC"},{"code":"85049","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.37,"maximum":17.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":17.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":17.47,"methodology":"fee schedule"}]}]},{"description":"PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC ","code_information":[{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":71983.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":312269.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":278143.920,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":312269.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":312269.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":28197.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":38012.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66159.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":42236.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":217840.450,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":32583.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":42236.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":68205.00,"methodology":"case rate"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":48729.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":57424.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":71983.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":32583.57,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":336577.520,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":373975.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":27650.02,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":35957.00,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":40860.00,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":32688.00,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":40860.00,"methodology":"case rate"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":46.90,"standard_charge_algorithm":"Reimbursement will be 46.9% of billable gross charges.","estimated_amount":219242.860,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":31944.68,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":25555.74,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":133976.550,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":247711.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":133976.550,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":33222.47,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":444095.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":199141.700,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":124814.160,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":30794.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":286558.360,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":31944.68,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":31944.68,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":29429.48,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":32903.02,"methodology":"fee schedule"}]}]},{"description":"CSTB (cystatin B), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, Short Tandem Requests (STR) expansions, mobile element insertions, and ","code_information":[{"code":"0232U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":219.86,"maximum":1170.45,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":480.38,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1170.45,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1170.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":219.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":285.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":276.20,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":285.82,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, lumbosacral; minimum of 4 views ","code_information":[{"code":"409","type":"RC"},{"code":"72110","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":64.20,"maximum":71.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":64.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":70.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":71.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":71.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.82,"methodology":"fee schedule"}]}]},{"description":"Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor ","code_information":[{"code":"38240","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve ","code_information":[{"code":"369","type":"RC"},{"code":"64405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area ","code_information":[{"code":"15271","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"125","type":"RC"},{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ul ","code_information":[{"code":"0620T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"155","type":"MS-DRG"},{"code":"214","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Blood typing, for paternity testing, per individual; ABO, Rh and MN ","code_information":[{"code":"86910","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":43.63,"maximum":103.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":43.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":101.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":48.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":48.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":103.43,"methodology":"fee schedule"}]}]},{"description":"MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC ","code_information":[{"code":"481","type":"RC"},{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bone marrow imaging; whole body ","code_information":[{"code":"341","type":"RC"},{"code":"78104","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":181.96,"maximum":202.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":181.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":200.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":202.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":202.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.72,"methodology":"fee schedule"}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"212","type":"RC"},{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious disease (bacterial and fungal), organism identification, blood culture, using rRNA FISH, 6 or more organism targets, reported as positive or negative with phenotypic minimum inhibitory conc ","code_information":[{"code":"0086U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":329.00,"maximum":780.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":329.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":768.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":365.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":365.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":780.00,"methodology":"fee schedule"}]}]},{"description":"Fibrinolytic factors and inhibitors; plasminogen activator ","code_information":[{"code":"309","type":"RC"},{"code":"85415","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.28,"maximum":67.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67.04,"methodology":"fee schedule"}]}]},{"description":"Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) ","code_information":[{"code":"306","type":"RC"},{"code":"87210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.57,"maximum":22.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22.70,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, internal auditory meati, complete ","code_information":[{"code":"409","type":"RC"},{"code":"70134","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":86.35,"maximum":95.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":86.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":95.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":95.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":95.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":95.26,"methodology":"fee schedule"}]}]},{"description":"Removal of lens material; intracapsular ","code_information":[{"code":"499","type":"RC"},{"code":"66920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC  IPF","code_information":[{"code":"124","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1004.09,"maximum":1024.17,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1024.17,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1004.09,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular ","code_information":[{"code":"33234","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical ","code_information":[{"code":"369","type":"RC"},{"code":"63285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radiologic examination, shoulder; 1 view ","code_information":[{"code":"323","type":"RC"},{"code":"73020","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":74.89,"maximum":83.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":74.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":82.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":83.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":83.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":82.61,"methodology":"fee schedule"}]}]},{"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":"311","type":"RC"},{"code":"80504","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":250.57,"maximum":594.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":250.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":585.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":278.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":278.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":594.05,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of greater humeral tuberosity fracture; without manipulation ","code_information":[{"code":"23620","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment ","code_information":[{"code":"L2116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":790.29,"maximum":1726.68,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1007.62,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1726.68,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1007.62,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1007.62,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":987.86,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":958.22,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":790.29,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1027.37,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":968.10,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":992.80,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":987.86,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":987.86,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1027.37,"methodology":"fee schedule"}]}]},{"description":"Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft) ","code_information":[{"code":"21366","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Corneal wedge resection for correction of surgically induced astigmatism ","code_information":[{"code":"360","type":"RC"},{"code":"65775","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Cross-over vein graft to venous system ","code_information":[{"code":"34520","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with insertion ","code_information":[{"code":"360","type":"RC"},{"code":"66991","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":42495.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":35253.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":42495.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Bypass graft, with other than vein; popliteal-tibial or -peroneal artery ","code_information":[{"code":"35671","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space ","code_information":[{"code":"0474T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Strapping; toes ","code_information":[{"code":"29550","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Repair of low imperforate anus; with transposition of anoperineal or anovestibular fistula ","code_information":[{"code":"361","type":"RC"},{"code":"46716","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"COMPLICATIONS OF TREATMENT WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"919","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"422","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores ","code_information":[{"code":"309","type":"RC"},{"code":"81504","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":855.40,"maximum":2028.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":855.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1998.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":950.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":950.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2028.00,"methodology":"fee schedule"}]}]},{"description":"MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medica ","code_information":[{"code":"322","type":"RC"},{"code":"76019","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":642.14,"maximum":713.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":642.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":708.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":713.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":713.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":708.35,"methodology":"fee schedule"}]}]},{"description":"Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal ","code_information":[{"code":"20962","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle ","code_information":[{"code":"0102T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Biopsy external auditory canal ","code_information":[{"code":"69105","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion ","code_information":[{"code":"360","type":"RC"},{"code":"52354","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"150","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Parathyroidectomy or exploration of parathyroid(s); re-exploration ","code_information":[{"code":"60502","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":" Magnetic Resonance Technology (MRT) MRA - Head and Neck  ","code_information":[{"code":"615","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1100.00,"maximum":3273.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1100.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1942.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1222.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":42.70,"standard_charge_algorithm":"Reimbursement will be 42.7% of billable gross charges.","estimated_amount":3524.490,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1222.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1942.00,"methodology":"other","additional_payer_notes":"Other Payment Notes: Per the billed unit for the service."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2051.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3273.00,"methodology":"case rate"},{"payer_name":"MVP Health Plan","plan_name":"COMM","standard_charge_dollar":2000.00,"methodology":"case rate"}]}]},{"description":"Gastroenterology (Barrett's esophagus), VIM and CCNA1 methylation analysis, esophageal cells, algorithm reported as likelihood for Barrett's esophagus ","code_information":[{"code":"0114U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3188.03,"maximum":7558.24,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3188.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7449.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3542.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3542.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":7558.24,"methodology":"fee schedule"}]}]},{"description":"Complete cbc, automated (hgb, hct, rbc, wbc, without platelet count) and automated wbc differential count ","code_information":[{"code":"306","type":"RC"},{"code":"G0306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12.78,"maximum":30.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":29.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":30.30,"methodology":"fee schedule"}]}]},{"description":"Aspiration and injection for treatment of bone cyst ","code_information":[{"code":"20615","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Vulvectomy simple; partial ","code_information":[{"code":"56620","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Drainage of scrotal wall abscess ","code_information":[{"code":"360","type":"RC"},{"code":"55100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PERSONALITY AND IMPULSE CONTROL  IPF","code_information":[{"code":"156","type":"RC"},{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1256.45,"maximum":1256.45,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1256.45,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Level 2 Blood Product Exch ","code_information":[{"code":"05242","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1731.78,"maximum":1749.63,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1731.78,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1749.63,"methodology":"fee schedule"}]}]},{"description":"Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction ","code_information":[{"code":"33244","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, hepatic, cel ","code_information":[{"code":"35121","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels ","code_information":[{"code":"400","type":"RC"},{"code":"77772","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":1444.70,"maximum":1604.91,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1444.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1593.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1604.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1604.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1593.67,"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":"87320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.68,"maximum":58.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.50,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) ","code_information":[{"code":"24363","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11152.90,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed ","code_information":[{"code":"302","type":"RC"},{"code":"81161","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":458.95,"maximum":1088.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":458.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1072.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":510.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":510.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1088.10,"methodology":"fee schedule"}]}]},{"description":"Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage ","code_information":[{"code":"27244","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Drainage external ear, abscess or hematoma; complicated ","code_information":[{"code":"69005","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Application of clubfoot cast with molding or manipulation, long or short leg ","code_information":[{"code":"29450","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection and anastomosis ","code_information":[{"code":"44227","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"369","type":"RC"},{"code":"58544","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Radiologic examination, eye, for detection of foreign body ","code_information":[{"code":"400","type":"RC"},{"code":"70030","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":171.21,"maximum":190.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":171.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":188.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":190.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":190.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":188.87,"methodology":"fee schedule"}]}]},{"description":"Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns which disrupt the pelvic ring, unilateral or bilateral, includes internal fixation, when performed (includes ","code_information":[{"code":"361","type":"RC"},{"code":"G0415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Valvuloplasty, mitral valve, with cardiopulmonary bypass; ","code_information":[{"code":"33425","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Exploration of penetrating wound (separate procedure); extremity ","code_information":[{"code":"20103","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy ","code_information":[{"code":"31239","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Biotinidase, each specimen ","code_information":[{"code":"82261","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.75,"maximum":65.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.79,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, temporomandibular joint, open and closed mouth; bilateral ","code_information":[{"code":"323","type":"RC"},{"code":"70330","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":218.45,"maximum":242.68,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":218.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":240.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":242.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":242.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":240.97,"methodology":"fee schedule"}]}]},{"description":"Inj, dostarlimab-gxly, 10 ","code_information":[{"code":"9431","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":194.97,"maximum":425.98,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":248.59,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":425.98,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":248.59,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":248.59,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":243.71,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":194.97,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":253.46,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":244.93,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":243.71,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":243.71,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":253.46,"methodology":"fee schedule"}]}]},{"description":"Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging ","code_information":[{"code":"323","type":"RC"},{"code":"75563","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and 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":1506.23,"maximum":1673.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1506.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1661.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1673.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1673.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1661.54,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of calcaneal fracture; without manipulation ","code_information":[{"code":"28400","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Reconstruction, toe(s); polydactyly ","code_information":[{"code":"28344","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) ","code_information":[{"code":"81345","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":148.16,"maximum":788.73,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":165.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":188.90,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":323.71,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":788.73,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":788.49,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":188.90,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":188.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":540.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":614.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":491.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":614.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":470.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":185.20,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":148.16,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":192.61,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":186.13,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":185.20,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":185.20,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":169.81,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":192.61,"methodology":"fee schedule"}]}]},{"description":"Peritoneal lavage, including imaging guidance, when performed ","code_information":[{"code":"360","type":"RC"},{"code":"49084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"67025","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Tenotomy, open, tendon flexor; toe, single tendon (separate procedure) ","code_information":[{"code":"28232","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75885","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":380.93,"maximum":423.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":380.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":420.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":423.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":423.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":420.20,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; with removal of foreign body(s) ","code_information":[{"code":"45332","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation ","code_information":[{"code":"0565T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Storage (per year); embryo(s) ","code_information":[{"code":"307","type":"RC"},{"code":"89342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) ","code_information":[{"code":"309","type":"RC"},{"code":"37678","type":"CDM"},{"code":"89060","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.06,"maximum":28.59,"gross_charge":239.00,"discounted_cash":239.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.59,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT ","code_information":[{"code":"143","type":"RC"},{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous ","code_information":[{"code":"499","type":"RC"},{"code":"53515","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Prochlorperazine maleate, 5 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 4 ","drug_information":{"unit":"5","type":"ME"},"code_information":[{"code":"72938","type":"CDM"},{"code":"Q0164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.40,"maximum":0.94,"gross_charge":11.00,"discounted_cash":11.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.63,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":0.94,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":0.94,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":0.44,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":0.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.40,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":0.50,"methodology":"fee schedule"}]}]},{"description":"Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral ","code_information":[{"code":"499","type":"RC"},{"code":"54900","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Pneumocystis jirovecii, amplified probe technique ","code_information":[{"code":"305","type":"RC"},{"code":"87594","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Arthrotomy, elbow, including exploration, drainage, or removal of foreign body ","code_information":[{"code":"24000","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus ","code_information":[{"code":"309","type":"RC"},{"code":"87902","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":423.51,"maximum":1004.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":423.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":989.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1004.05,"methodology":"fee schedule"}]}]},{"description":"Nephelometry, each analyte not elsewhere specified ","code_information":[{"code":"301","type":"RC"},{"code":"49415","type":"CDM"},{"code":"83883","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.37,"maximum":53.04,"gross_charge":164.50,"discounted_cash":164.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":52.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.04,"methodology":"fee schedule"}]}]},{"description":"Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric ","code_information":[{"code":"L6712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1166.82,"maximum":2549.35,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1487.69,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2549.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1487.69,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1487.69,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1458.52,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1414.76,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1166.82,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1516.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1429.35,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1465.81,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1458.52,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1458.52,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1516.86,"methodology":"fee schedule"}]}]},{"description":"Enterocystoplasty, including intestinal anastomosis ","code_information":[{"code":"51960","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Bone length studies (orthoroentgenogram, scanogram) ","code_information":[{"code":"400","type":"RC"},{"code":"77073","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":65.59,"maximum":72.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":65.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":72.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":72.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":72.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":72.35,"methodology":"fee schedule"}]}]},{"description":"Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family ","code_information":[{"code":"36216","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"36906","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"SEPTIC ARTHRITIS WITH CC ","code_information":[{"code":"147","type":"RC"},{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision tracheal stenosis and anastomosis; cervical ","code_information":[{"code":"31780","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Chloride; other source ","code_information":[{"code":"307","type":"RC"},{"code":"82438","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.22,"maximum":19.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.50,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; adenovirus ","code_information":[{"code":"87809","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":35.80,"maximum":84.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":35.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":39.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":39.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":84.86,"methodology":"fee schedule"}]}]},{"description":"Injections of stem cell product into perianal perifistular soft tissue, including fistula preparation (eg, removal of setons, fistula curettage, closure of internal openings) ","code_information":[{"code":"0748T","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair of defect with autograft; radius OR ulna ","code_information":[{"code":"25425","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical ","code_information":[{"code":"22220","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Oncology (lung), three protein biomarkers, immunoassay using Q4 magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy ","code_information":[{"code":"0092U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4092.76,"maximum":9703.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4092.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9563.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4548.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4548.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9703.20,"methodology":"fee schedule"}]}]},{"description":"Cast supplies, short arm splint, adult (11 years +), fiberglass ","code_information":[{"code":"Q4022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12.16,"maximum":26.57,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":15.50,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":26.57,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":15.50,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":15.50,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":15.20,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":14.74,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":12.16,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":15.81,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15.28,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":15.20,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":15.20,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":15.81,"methodology":"fee schedule"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius ","code_information":[{"code":"25490","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITHOUT MCC ","code_information":[{"code":"125","type":"RC"},{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation ","code_information":[{"code":"25680","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"PLEURAL EFFUSION WITH CC ","code_information":[{"code":"121","type":"RC"},{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less ","code_information":[{"code":"11600","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC ","code_information":[{"code":"361","type":"RC"},{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Manipulation, finger joint, under anesthesia, each joint ","code_information":[{"code":"26340","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure) ","code_information":[{"code":"0397T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) ","code_information":[{"code":"300","type":"RC"},{"code":"81363","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":332.95,"maximum":789.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":332.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":778.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":369.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":369.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":789.36,"methodology":"fee schedule"}]}]},{"description":"Oncology (thyroid), DNA and mRNA, next generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic prediction of cancer recurrence, ","code_information":[{"code":"0287U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5922.00,"maximum":14040.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5922.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":13838.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6580.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6580.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14040.00,"methodology":"fee schedule"}]}]},{"description":"BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom syndrome) gene analysis, 2281del6ins7 variant ","code_information":[{"code":"305","type":"RC"},{"code":"81209","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":64.66,"maximum":153.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":64.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":151.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":71.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":71.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":153.31,"methodology":"fee schedule"}]}]},{"description":"Venous catheterization for selective organ blood sampling ","code_information":[{"code":"36500","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"REHABILITATION WITH CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk ","code_information":[{"code":"369","type":"RC"},{"code":"G0121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Free omental flap with microvascular anastomosis ","code_information":[{"code":"361","type":"RC"},{"code":"49906","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Injection, glofitamab-gxbm, 2.5 mg ","code_information":[{"code":"J9286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2689.62,"maximum":7431.58,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3532.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4059.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3924.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":3226.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3924.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4844.83,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":7431.58,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7431.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":3370.26,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":3829.40,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3063.52,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":3829.40,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2689.62,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2717.34,"methodology":"fee schedule"}]}]},{"description":"PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC ","code_information":[{"code":"337","type":"MS-DRG"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies ","code_information":[{"code":"84689","type":"CDM"},{"code":"87806","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.22,"maximum":139.56,"gross_charge":163.50,"discounted_cash":163.50,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":29.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":33.43,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":57.28,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":139.56,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":139.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":33.43,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":33.43,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":95.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":108.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":86.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":108.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":83.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":32.77,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":32.86,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":26.22,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":34.08,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":33.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":32.93,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":32.77,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":32.77,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":30.05,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":34.08,"methodology":"fee schedule"}]}]},{"description":"Application of short arm splint (forearm to hand); dynamic ","code_information":[{"code":"29126","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Organic acids; total, quantitative, each specimen ","code_information":[{"code":"301","type":"RC"},{"code":"83918","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":38.82,"maximum":92.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":38.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":90.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":43.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":43.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":92.04,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia ","code_information":[{"code":"26670","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling ","code_information":[{"code":"349","type":"RC"},{"code":"78110","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":38.45,"maximum":42.71,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":38.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":42.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":42.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":42.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":42.41,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"210","type":"RC"},{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"118","type":"RC"},{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 ","code_information":[{"code":"22554","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11152.90,"maximum":35000.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26550.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Curettage, postpartum ","code_information":[{"code":"490","type":"RC"},{"code":"59160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm ","code_information":[{"code":"17282","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 cm or greater ","code_information":[{"code":"28047","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material ","code_information":[{"code":"323","type":"RC"},{"code":"74176","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":961.90,"maximum":1068.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":961.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1061.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1068.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1068.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1061.08,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft) ","code_information":[{"code":"26842","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"EPISTAXIS WITHOUT MCC ","code_information":[{"code":"145","type":"RC"},{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar ","code_information":[{"code":"22114","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair ","code_information":[{"code":"11471","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) ","code_information":[{"code":"499","type":"RC"},{"code":"65600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC ","code_information":[{"code":"060","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection procedure for elbow arthrography ","code_information":[{"code":"24220","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Therapeutic apheresis with selective HDL delipidation and plasma reinfusion ","code_information":[{"code":"0342T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"38747","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Excision of infected graft; neck ","code_information":[{"code":"35901","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List separately in addition to code for primary procedure) ","code_information":[{"code":"26863","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER VASCULAR PROCEDURES WITH CC ","code_information":[{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":70188.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":190260.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":169468.640,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":190260.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":190260.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":18410.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":63169.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":70188.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":70188.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":132726.700,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":20500.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":70188.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70188.00,"methodology":"case rate"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":30658.45,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":45839.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":57460.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":20500.29,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":205071.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":227857.000,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":18053.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":62660.680,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":71233.790,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":56964.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":71233.790,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":128198.040,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":20098.32,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":16078.66,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":81629.770,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":150926.780,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":81629.770,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":20902.25,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":270580.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":121333.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":76047.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":19374.78,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":174595.430,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":20098.32,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":20098.32,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":19214.96,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":20701.27,"methodology":"fee schedule"}]}]},{"description":"Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable moni ","code_information":[{"code":"0527T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Transcortin (cortisol binding globulin) ","code_information":[{"code":"307","type":"RC"},{"code":"84449","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29.61,"maximum":70.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":69.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.20,"methodology":"fee schedule"}]}]},{"description":"Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor ","code_information":[{"code":"50562","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each ","code_information":[{"code":"369","type":"RC"},{"code":"44720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u. ","code_information":[{"code":"J7202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.02,"maximum":13.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":6.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9.06,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":13.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":13.97,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":6.34,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":7.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":5.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":7.20,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5.02,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5.08,"methodology":"fee schedule"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, inclu ","code_information":[{"code":"360","type":"RC"},{"code":"43276","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown ","code_information":[{"code":"361","type":"RC"},{"code":"36640","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material ","code_information":[{"code":"329","type":"RC"},{"code":"72146","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1002.71,"maximum":1113.91,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1002.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1106.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1113.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1113.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1106.10,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"369","type":"RC"},{"code":"58573","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"096","type":"MS-DRG"},{"code":"140","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) ","code_information":[{"code":"G0279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":12.58,"maximum":114.10,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":16.03,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":27.48,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":114.10,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":114.10,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":16.03,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":16.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":15.72,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":15.26,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":12.58,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":16.35,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":15.42,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":15.80,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":15.72,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":15.72,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":16.35,"methodology":"fee schedule"}]}]},{"description":"Tenecteplase injection ","code_information":[{"code":"09002","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":167.05,"maximum":168.78,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":167.05,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":168.78,"methodology":"fee schedule"}]}]},{"description":"Repair of patent ductus arteriosus; by division, 18 years and older ","code_information":[{"code":"33824","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC ","code_information":[{"code":"149","type":"RC"},{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"182","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Gastrointestinal endoscopic ultrasound, supervision and interpretation ","code_information":[{"code":"402","type":"RC"},{"code":"76975","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":202.88,"maximum":225.37,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":202.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":223.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":223.79,"methodology":"fee schedule"}]}]},{"description":"Injection, romidepsin, lyophilized, 0.1 mg ","code_information":[{"code":"J9319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":30.59,"maximum":81.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":38.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":43.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":35.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":43.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.29,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":81.51,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":81.51,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":36.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":42.00,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":33.60,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":42.00,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":30.59,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":30.91,"methodology":"fee schedule"}]}]},{"description":"Flortaucipir inj 1 millicu ","code_information":[{"code":"00709","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":3598.70,"maximum":3635.80,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3598.70,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3635.80,"methodology":"fee schedule"}]}]},{"description":"Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm ","code_information":[{"code":"17107","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy ","code_information":[{"code":"499","type":"RC"},{"code":"64763","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"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":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":585.83,"maximum":1388.91,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":585.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1368.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":651.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":651.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1388.91,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"688","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Flurpiridaz f18, diag, 1 m ","code_information":[{"code":"2065","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":424.00,"maximum":926.39,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":540.60,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":926.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":540.60,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":540.60,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":530.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":424.00,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":551.20,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":532.65,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":530.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":530.00,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":551.20,"methodology":"fee schedule"}]}]},{"description":"Reduction of torsion of testis, surgical, with or without fixation of contralateral testis ","code_information":[{"code":"361","type":"RC"},{"code":"54600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue ","code_information":[{"code":"65280","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each ","code_information":[{"code":"302","type":"RC"},{"code":"37340","type":"CDM"},{"code":"86003","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.59,"maximum":20.36,"gross_charge":237.00,"discounted_cash":237.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":20.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20.36,"methodology":"fee schedule"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC ","code_information":[{"code":"324","type":"MS-DRG"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Peanut allergen-specific IgE and quantitative assessment of 64 epitopes using enzyme-linked immunosorbent assay (ELISA), blood, individual epitope results and interpretation ","code_information":[{"code":"0165U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":762.89,"maximum":1808.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":762.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1782.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":847.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":847.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1808.66,"methodology":"fee schedule"}]}]},{"description":"HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC ","code_information":[{"code":"353","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20781.61,"maximum":20995.85,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":20781.61,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":20995.85,"methodology":"fee schedule"}]}]},{"description":"CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, ","code_information":[{"code":"0070U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1112.63,"maximum":2637.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1112.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2599.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1236.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1236.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2637.84,"methodology":"fee schedule"}]}]},{"description":"Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy ","code_information":[{"code":"27441","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":24133.40,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":24133.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":24133.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":24133.40,"methodology":"case rate"}]}]},{"description":"Removal of lens material; intracapsular, for dislocated lens ","code_information":[{"code":"490","type":"RC"},{"code":"66930","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITH MCC ","code_information":[{"code":"070","type":"MS-DRG"},{"code":"202","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous defibrillation lead only ","code_information":[{"code":"0921T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Radical resection of tumor; tibia ","code_information":[{"code":"27645","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) ","code_information":[{"code":"323","type":"RC"},{"code":"71555","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":1330.80,"maximum":1478.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1330.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1468.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1478.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1478.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1468.02,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage, thoracic ","code_information":[{"code":"490","type":"RC"},{"code":"63197","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration ","code_information":[{"code":"361","type":"RC"},{"code":"61580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 1 ","code_information":[{"code":"87274","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.58,"maximum":51.04,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":12.22,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":20.94,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":51.04,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":51.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":12.22,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":12.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":38.88,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":44.18,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":35.35,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":44.18,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":33.87,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":11.98,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12.02,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9.58,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12.14,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.04,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11.98,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":11.98,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":10.98,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12.46,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of posterior malleolus fracture; with manipulation ","code_information":[{"code":"27768","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Reimplantation of an anomalous pulmonary artery ","code_information":[{"code":"33788","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection, sebelipase alfa, 1 mg ","code_information":[{"code":"J2840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":575.70,"maximum":1396.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":666.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":765.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":740.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":608.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":740.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":913.80,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1396.54,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1396.54,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":633.34,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":719.62,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":575.70,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":719.62,"methodology":"fee schedule"}]}]},{"description":"Troponin, quantitative ","code_information":[{"code":"302","type":"RC"},{"code":"84484","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.51,"maximum":48.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":47.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.63,"methodology":"fee schedule"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"146","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1180.48,"maximum":1180.48,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1180.48,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation ","code_information":[{"code":"50385","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome) ","code_information":[{"code":"499","type":"RC"},{"code":"61340","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graf ","code_information":[{"code":"26123","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"32574","type":"CDM"},{"code":"75809","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":420.40,"maximum":467.02,"gross_charge":2028.50,"discounted_cash":2028.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":420.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":463.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":467.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":467.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":463.75,"methodology":"fee schedule"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC ","code_information":[{"code":"053","type":"MS-DRG"},{"code":"116","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Esophagoplasty (plastic repair or reconstruction), cervical approach; without repair of tracheoesophageal fistula ","code_information":[{"code":"43300","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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":"87340","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":16.99,"maximum":40.29,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40.29,"methodology":"fee schedule"}]}]},{"description":"PABPN1 (polyºA» binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"81312","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"SEPTIC ARTHRITIS WITH CC ","code_information":[{"code":"115","type":"RC"},{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator ","code_information":[{"code":"31527","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Incision of thrombosed hemorrhoid, external ","code_information":[{"code":"369","type":"RC"},{"code":"46083","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"OTHER MENTAL DISORDER DIAGNOSES  IPF","code_information":[{"code":"146","type":"RC"},{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1193.21,"maximum":1193.21,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1193.21,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"289","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"300","type":"RC"},{"code":"81355","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":145.09,"maximum":343.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":145.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":339.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":161.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":161.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":343.98,"methodology":"fee schedule"}]}]},{"description":"Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access ","code_information":[{"code":"36585","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial vessel ","code_information":[{"code":"35305","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Adenoidectomy, primary; age 12 or over ","code_information":[{"code":"42831","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar ","code_information":[{"code":"22325","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision ","code_information":[{"code":"923","type":"RC"},{"code":"G0147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":24.92,"maximum":59.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":58.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":59.09,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC  IPF","code_information":[{"code":"057","type":"MS-DRG"},{"code":"144","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1103.72,"maximum":1125.79,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1125.79,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1103.72,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Radiologic examination, eye, for detection of foreign body ","code_information":[{"code":"321","type":"RC"},{"code":"70030","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.79,"maximum":48.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":43.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":48.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":48.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":48.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.31,"methodology":"fee schedule"}]}]},{"description":"Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter ","code_information":[{"code":"636","type":"RC"},{"code":"Q4105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_percentage":21.40,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3780 reimbursement is 21.4% of aggregated billable gross charges. If aggregated billable gross charges are less than $3780 then reimbursement for the specified code will be zero.","estimated_amount":4956.890,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_percentage":23.80,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3780 reimbursement is 23.8% of aggregated billable gross charges. If aggregated billable gross charges are less than $3780 then reimbursement for the specified code will be zero.","estimated_amount":5512.810,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_percentage":23.80,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3780 reimbursement is 23.8% of aggregated billable gross charges. If aggregated billable gross charges are less than $3780 then reimbursement for the specified code will be zero.","estimated_amount":5512.810,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_percentage":23.80,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3780 reimbursement is 23.8% of aggregated billable gross charges. If aggregated billable gross charges are less than $3780 then reimbursement for the specified code will be zero.","estimated_amount":5512.810,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_percentage":23.80,"standard_charge_algorithm":"In addition if aggregated billable gross charges for specific code exceed $3780 reimbursement is 23.8% of aggregated billable gross charges. If aggregated billable gross charges are less than $3780 then reimbursement for the specified code will be zero.","estimated_amount":5512.810,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."}]}]},{"description":"Suture of esophageal wound or injury; cervical approach ","code_information":[{"code":"43410","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Oncoprotein; des-gamma-carboxy-prothrombin (DCP) ","code_information":[{"code":"303","type":"RC"},{"code":"83951","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":105.95,"maximum":251.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":105.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":247.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":117.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":117.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":251.20,"methodology":"fee schedule"}]}]},{"description":"Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy ","code_information":[{"code":"490","type":"RC"},{"code":"59121","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Culture, mycobacterial, definitive identification, each isolate ","code_information":[{"code":"87118","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.69,"maximum":62.24,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":13.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":14.90,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":25.54,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":62.24,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":62.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":14.90,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":14.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":42.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":48.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":38.77,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":48.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":37.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":14.61,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":14.66,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":11.69,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":15.19,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14.81,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14.68,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":14.61,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":14.61,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":13.40,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":15.19,"methodology":"fee schedule"}]}]},{"description":"Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance, when performed, including autogenous or nonautogenous patch graft (eg, polyester, ePTFE, bovine peri ","code_information":[{"code":"0744T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":14872.70,"methodology":"case rate"}]}]},{"description":"Ablation, open, of 1 or more liver tumor(s); cryosurgical ","code_information":[{"code":"47381","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS ","code_information":[{"code":"113","type":"RC"},{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cortisol; free ","code_information":[{"code":"82530","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.49,"maximum":65.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.17,"methodology":"fee schedule"}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"545","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) ","code_information":[{"code":"36832","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal ","code_information":[{"code":"361","type":"RC"},{"code":"69801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Volume measurement for timed collection, each ","code_information":[{"code":"303","type":"RC"},{"code":"81050","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5.99,"maximum":14.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":13.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14.20,"methodology":"fee schedule"}]}]},{"description":"Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor ","code_information":[{"code":"490","type":"RC"},{"code":"60545","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon ","code_information":[{"code":"43290","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Radiologic examination, shoulder; 1 view ","code_information":[{"code":"320","type":"RC"},{"code":"73020","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":74.89,"maximum":83.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":74.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":82.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":83.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":83.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":82.61,"methodology":"fee schedule"}]}]},{"description":"Cordocentesis (intrauterine), any method ","code_information":[{"code":"481","type":"RC"},{"code":"59012","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater ","code_information":[{"code":"21016","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC ","code_information":[{"code":"130","type":"RC"},{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"409","type":"RC"},{"code":"72194","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1322.32,"maximum":1468.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1322.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1458.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1468.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1468.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1458.66,"methodology":"fee schedule"}]}]},{"description":"Addition to lower extremity, straight knee joint, heavy duty, each joint ","code_information":[{"code":"L2385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":153.88,"maximum":336.21,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":196.20,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":336.21,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":196.20,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":196.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":192.35,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":186.58,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":153.88,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":200.04,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":188.50,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":193.31,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":192.35,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":192.35,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":200.04,"methodology":"fee schedule"}]}]},{"description":"Trabecular bone score (TBS), structural condition of the bone microarchitecture; technical preparation and transmission of data for analysis to be performed elsewhere ","code_information":[{"code":"324","type":"RC"},{"code":"77090","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.37,"maximum":17.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.95,"methodology":"fee schedule"}]}]},{"description":"ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs, E122fs, R448fs) ","code_information":[{"code":"305","type":"RC"},{"code":"81360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":317.90,"maximum":753.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":742.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":353.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":753.67,"methodology":"fee schedule"}]}]},{"description":"SKIN DEBRIDEMENT WITH MCC ","code_information":[{"code":"570","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22042.28,"maximum":22269.52,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":22042.28,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":22269.52,"methodology":"fee schedule"}]}]},{"description":"Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each ","code_information":[{"code":"A4358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":6.30,"maximum":13.77,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":8.04,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":13.77,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":8.04,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":8.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":7.64,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":6.30,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":8.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":7.72,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7.92,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":8.20,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITHOUT CC/MCC ","code_information":[{"code":"110","type":"RC"},{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Alpha-1-antitrypsin; total ","code_information":[{"code":"305","type":"RC"},{"code":"82103","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.11,"maximum":52.42,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.42,"methodology":"fee schedule"}]}]},{"description":"Tissue marker, detectable ","code_information":[{"code":"2055","type":"APC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_percentage":7.04,"standard_charge_algorithm":"Reimbursement will be 7.04% of billable gross charges.","estimated_amount":835.700,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_percentage":12.06,"standard_charge_algorithm":"Reimbursement will be 12.06% of billable gross charges.","estimated_amount":1431.610,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_percentage":7.04,"standard_charge_algorithm":"Reimbursement will be 7.04% of billable gross charges.","estimated_amount":835.700,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_percentage":7.04,"standard_charge_algorithm":"Reimbursement will be 7.04% of billable gross charges.","estimated_amount":835.700,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Humana","plan_name":"MCR","standard_charge_percentage":6.90,"standard_charge_algorithm":"Reimbursement will be 6.9% of billable gross charges.","estimated_amount":819.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_percentage":5.52,"standard_charge_algorithm":"Reimbursement will be 5.52% of billable gross charges.","estimated_amount":655.260,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_percentage":7.18,"standard_charge_algorithm":"Reimbursement will be 7.18% of billable gross charges.","estimated_amount":852.320,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_percentage":6.93,"standard_charge_algorithm":"Reimbursement will be 6.93% of billable gross charges.","estimated_amount":822.640,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_percentage":6.90,"standard_charge_algorithm":"Reimbursement will be 6.9% of billable gross charges.","estimated_amount":819.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_percentage":6.90,"standard_charge_algorithm":"Reimbursement will be 6.9% of billable gross charges.","estimated_amount":819.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_percentage":7.18,"standard_charge_algorithm":"Reimbursement will be 7.18% of billable gross charges.","estimated_amount":852.320,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."}]}]},{"description":"Tobramycin ","code_information":[{"code":"305","type":"RC"},{"code":"80200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.53,"maximum":62.91,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.91,"methodology":"fee schedule"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"325","type":"MS-DRG"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HLA Class II typing, low resolution (eg, antigen equivalents); HLA-DRB1/3/4/5 and -DQB1 ","code_information":[{"code":"309","type":"RC"},{"code":"81375","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":363.12,"maximum":860.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":363.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":848.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":403.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":403.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":860.89,"methodology":"fee schedule"}]}]},{"description":"Rare diseases (constitutional/heritble disorders),whole genome seq analysis for chromosonal abnormalities, copy number variants,duplications,deletions,inversions,unbalanced translocations,regions of ","code_information":[{"code":"0469U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1970.61,"maximum":4671.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1970.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4604.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2189.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2189.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4671.97,"methodology":"fee schedule"}]}]},{"description":"End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age ","code_information":[{"code":"90968","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.69,"maximum":13.83,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":13.69,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":13.83,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation ","code_information":[{"code":"27825","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Medial canthopexy (separate procedure) ","code_information":[{"code":"21280","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Radiologic examination, single plane body section (eg, tomography), other than with urography ","code_information":[{"code":"321","type":"RC"},{"code":"76100","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":317.86,"maximum":353.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":350.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":353.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":353.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":350.63,"methodology":"fee schedule"}]}]},{"description":"Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple ","code_information":[{"code":"361","type":"RC"},{"code":"67808","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Radiologic examination, knee; complete, 4 or more views ","code_information":[{"code":"321","type":"RC"},{"code":"73564","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":55.77,"maximum":61.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":61.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":61.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.52,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"120","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transcutaneous measurement of five biomarkers, using spatial frequency domain imaging (SFDI) and multi-spectral analysis ","code_information":[{"code":"0061U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":41.29,"maximum":97.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":41.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":96.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":45.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":45.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":97.89,"methodology":"fee schedule"}]}]},{"description":"Prothrombin time; ","code_information":[{"code":"302","type":"RC"},{"code":"85610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.06,"maximum":16.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.73,"methodology":"fee schedule"}]}]},{"description":"Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each ","code_information":[{"code":"361","type":"RC"},{"code":"63044","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":690.91,"payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery ","code_information":[{"code":"369","type":"RC"},{"code":"46916","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"130","type":"RC"},{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CONCUSSION WITH CC ","code_information":[{"code":"089","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s) ","code_information":[{"code":"360","type":"RC"},{"code":"61891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip ","code_information":[{"code":"27823","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, ima ","code_information":[{"code":"0524T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITH CC ","code_information":[{"code":"133","type":"RC"},{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Fluorescent noninfectious agent antibody; screen, each antibody ","code_information":[{"code":"305","type":"RC"},{"code":"86255","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.82,"maximum":47.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47.00,"methodology":"fee schedule"}]}]},{"description":"Trabecular bone score (TBS), structural condition of the bone microarchitecture; technical preparation and transmission of data for analysis to be performed elsewhere ","code_information":[{"code":"400","type":"RC"},{"code":"77090","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.37,"maximum":17.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.95,"methodology":"fee schedule"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC ","code_information":[{"code":"120","type":"RC"},{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bypass graft, with other than vein; subclavian-subclavian ","code_information":[{"code":"35612","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"ESOPH ENDOSCOPY ABLATION ","code_information":[{"code":"43228","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2000.00,"maximum":2000.00,"payers_information":[{"payer_name":"MVP Health Plan","plan_name":"COMM","standard_charge_dollar":2000.00,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"072","type":"MS-DRG"},{"code":"150","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC ","code_information":[{"code":"096","type":"MS-DRG"},{"code":"148","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SEPTIC ARTHRITIS WITHOUT CC/MCC ","code_information":[{"code":"141","type":"RC"},{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Porphyrins, urine; qualitative ","code_information":[{"code":"309","type":"RC"},{"code":"84119","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.98,"maximum":52.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.10,"methodology":"fee schedule"}]}]},{"description":"Oncoprotein; HER-2/neu ","code_information":[{"code":"301","type":"RC"},{"code":"83950","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":105.95,"maximum":251.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":105.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":247.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":117.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":117.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":251.20,"methodology":"fee schedule"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"150","type":"RC"},{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement ","code_information":[{"code":"360","type":"RC"},{"code":"50948","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Excision of infected graft; thorax ","code_information":[{"code":"35905","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Antibody; Neisseria meningitidis ","code_information":[{"code":"304","type":"RC"},{"code":"86741","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.70,"maximum":51.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.44,"methodology":"fee schedule"}]}]},{"description":"Nerve pedicle transfer; first stage ","code_information":[{"code":"369","type":"RC"},{"code":"64905","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC ","code_information":[{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":26105.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":88946.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":79226.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":88946.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":88946.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7060.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6700.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":24869.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7445.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":62049.760,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":7342.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7445.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20146.60,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":10981.34,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":7342.85,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":95870.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":106523.200,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":6923.12,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":29293.880,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":33301.820,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":26630.800,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":33301.820,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":59932.620,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":7198.88,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":5759.10,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":38161.940,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":70558.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":38161.940,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":7486.83,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":126496.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":56723.600,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":35552.120,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6939.72,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":81623.400,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":7198.88,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":7198.88,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":7368.66,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":7414.84,"methodology":"fee schedule"}]}]},{"description":"Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of maligna ","code_information":[{"code":"0245U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2082.69,"maximum":4937.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2082.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4866.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2314.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2314.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4937.67,"methodology":"fee schedule"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"099","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Medial canthopexy (separate procedure) ","code_information":[{"code":"21280","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Excision of perinephric cyst ","code_information":[{"code":"499","type":"RC"},{"code":"50290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC ","code_information":[{"code":"121","type":"RC"},{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance ","code_information":[{"code":"32555","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Parainfluenza virus, each type ","code_information":[{"code":"307","type":"RC"},{"code":"87279","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.03,"maximum":64.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":64.08,"methodology":"fee schedule"}]}]},{"description":"Amiodarone ","code_information":[{"code":"301","type":"RC"},{"code":"48876","type":"CDM"},{"code":"80151","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.66,"maximum":72.70,"gross_charge":131.00,"discounted_cash":131.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":71.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":72.70,"methodology":"fee schedule"}]}]},{"description":"Antibody; Leptospira ","code_information":[{"code":"300","type":"RC"},{"code":"86720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.65,"maximum":63.18,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63.18,"methodology":"fee schedule"}]}]},{"description":"Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) ","code_information":[{"code":"490","type":"RC"},{"code":"64488","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduc ","code_information":[{"code":"99391","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":53.11,"maximum":53.66,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":53.11,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":53.66,"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, radial or ul ","code_information":[{"code":"35045","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Proctoplasty; for prolapse of mucous membrane ","code_information":[{"code":"45505","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"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":"369","type":"RC"},{"code":"C7562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session ","code_information":[{"code":"361","type":"RC"},{"code":"54416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"042","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":11187.05,"maximum":11302.38,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":11187.05,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":11302.38,"methodology":"fee schedule"}]}]},{"description":"Excision of tendon, finger, flexor or extensor, each tendon ","code_information":[{"code":"26180","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) ","code_information":[{"code":"33412","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery ","code_information":[{"code":"61538","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision ","code_information":[{"code":"31085","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19023.00,"maximum":22929.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"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":"329","type":"RC"},{"code":"74251","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1825.52,"maximum":2027.96,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1825.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2013.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2027.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2027.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2013.76,"methodology":"fee schedule"}]}]},{"description":"Therapeutic radiology treatment planning; intermediate ","code_information":[{"code":"409","type":"RC"},{"code":"77262","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":554.40,"maximum":615.88,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":554.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":611.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":615.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":615.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":611.57,"methodology":"fee schedule"}]}]},{"description":"Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed ","code_information":[{"code":"324","type":"RC"},{"code":"77778","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4826.56,"maximum":5361.80,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4826.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5324.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5361.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5361.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5324.24,"methodology":"fee schedule"}]}]},{"description":"Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed ","code_information":[{"code":"341","type":"RC"},{"code":"76881","type":"CDM"},{"code":"78598","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1402.09,"maximum":1557.57,"gross_charge":4688.25,"discounted_cash":4688.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1402.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1546.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1557.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1557.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1546.66,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"72149","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":996.80,"maximum":1107.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":996.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1099.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1107.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1107.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1099.58,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater ","code_information":[{"code":"21014","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Injection, milrinone lactate, 5 mg ","drug_information":{"unit":"40","type":"ME"},"code_information":[{"code":"71407","type":"CDM"},{"code":"J2260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.45,"maximum":3.51,"gross_charge":518.25,"discounted_cash":518.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":1.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2.49,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3.51,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3.51,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1.59,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.81,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.81,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1.52,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1.54,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s) ","code_information":[{"code":"499","type":"RC"},{"code":"52240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection ","code_information":[{"code":"61020","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Appendectomy; for ruptured appendix with abscess or generalized peritonitis ","code_information":[{"code":"44960","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Colpocleisis (Le Fort type) ","code_information":[{"code":"57120","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision of synovial cyst of popliteal space (eg, Baker's cyst) ","code_information":[{"code":"27345","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family ","code_information":[{"code":"36247","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Splenectomy; partial (separate procedure) ","code_information":[{"code":"38101","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"138","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Venography, adrenal, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75842","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":355.64,"maximum":395.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":355.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":392.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":395.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":395.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":392.31,"methodology":"fee schedule"}]}]},{"description":"Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, fe ","code_information":[{"code":"0802T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision ","code_information":[{"code":"33891","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"321","type":"RC"},{"code":"74170","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":1037.41,"maximum":1152.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1037.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1144.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1152.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1152.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1144.38,"methodology":"fee schedule"}]}]},{"description":"HEADACHES WITHOUT MCC ","code_information":[{"code":"103","type":"MS-DRG"},{"code":"151","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed ","code_information":[{"code":"44408","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Vasovasostomy, vasovasorrhaphy ","code_information":[{"code":"499","type":"RC"},{"code":"55400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"56501","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"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":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC ","code_information":[{"code":"074","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of posterior malleolus fracture; without manipulation ","code_information":[{"code":"27767","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Removal of lens material; intracapsular, for dislocated lens ","code_information":[{"code":"499","type":"RC"},{"code":"66930","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Open treatment of humeral shaft fracture with plate/screws, with or without cerclage ","code_information":[{"code":"24515","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75746","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":260.60,"maximum":289.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":260.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":287.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":289.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":289.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":287.47,"methodology":"fee schedule"}]}]},{"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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"134","type":"RC"},{"code":"869","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"061","type":"MS-DRG"},{"code":"118","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"304","type":"RC"},{"code":"81462","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1967.14,"maximum":4663.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1967.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4596.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2185.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2185.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4663.74,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) ","code_information":[{"code":"400","type":"RC"},{"code":"72142","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":427.60,"maximum":475.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":427.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":471.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":475.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":475.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":471.69,"methodology":"fee schedule"}]}]},{"description":"Dermabrasion; regional, other than face ","code_information":[{"code":"15782","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Humidifier, durable for supplemental humidification during ippb treatment or oxygen delivery ","code_information":[{"code":"E0560","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":165.22,"maximum":360.99,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":360.99,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":210.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":206.53,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":200.33,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":165.22,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":214.79,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":202.40,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":207.56,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":206.53,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":206.53,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":214.79,"methodology":"fee schedule"}]}]},{"description":"Calculus; X-ray diffraction ","code_information":[{"code":"82370","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":20.60,"maximum":48.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":48.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.83,"methodology":"fee schedule"}]}]},{"description":"Iodine i-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries) ","code_information":[{"code":"A9531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":9.57,"maximum":9.57,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9.57,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9.57,"methodology":"fee schedule"}]}]},{"description":"Insertion of peritoneal-venous shunt ","code_information":[{"code":"49425","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Amputation, metatarsal, with toe, single ","code_information":[{"code":"28810","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inf ","code_information":[{"code":"33933","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Calculus; infrared spectroscopy ","code_information":[{"code":"305","type":"RC"},{"code":"82365","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.22,"maximum":50.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.31,"methodology":"fee schedule"}]}]},{"description":"Open treatment of radial shaft fracture, includes internal fixation, when performed ","code_information":[{"code":"25515","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"116","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":994.34,"maximum":994.34,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":994.34,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"148","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification ","code_information":[{"code":"301","type":"RC"},{"code":"87517","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.47,"maximum":167.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":70.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":164.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":78.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":78.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":167.08,"methodology":"fee schedule"}]}]},{"description":"Transfer, finger to another position without microvascular anastomosis ","code_information":[{"code":"26555","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thromboplastin inhibition, tissue ","code_information":[{"code":"307","type":"RC"},{"code":"85705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.84,"maximum":37.56,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37.56,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique ","code_information":[{"code":"87581","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Coccygectomy, primary ","code_information":[{"code":"27080","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid ","code_information":[{"code":"41006","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Vitamin A ","code_information":[{"code":"301","type":"RC"},{"code":"37877","type":"CDM"},{"code":"84590","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.10,"maximum":45.28,"gross_charge":691.50,"discounted_cash":691.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45.28,"methodology":"fee schedule"}]}]},{"description":"Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel ","code_information":[{"code":"400","type":"RC"},{"code":"77767","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1305.66,"maximum":1450.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1305.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1440.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1450.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1450.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1440.29,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) ","code_information":[{"code":"480","type":"RC"},{"code":"92925","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18354.00,"maximum":32157.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18354.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":32157.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":20393.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":32157.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic ","code_information":[{"code":"22222","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"INBORN AND OTHER DISORDERS OF METABOLISM ","code_information":[{"code":"148","type":"RC"},{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing at least 20 molecular features, saliva, algorithm reported as positive or negative for signature associated wit ","code_information":[{"code":"0296U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2886.97,"maximum":6844.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2886.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6746.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6844.50,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic ","code_information":[{"code":"323","type":"RC"},{"code":"72157","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":1138.61,"maximum":1264.88,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1138.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1256.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1264.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1264.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1256.02,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) ","code_information":[{"code":"323","type":"RC"},{"code":"70481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":950.08,"maximum":1055.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":950.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1048.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1055.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1055.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1048.04,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC ","code_information":[{"code":"155","type":"RC"},{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm ","code_information":[{"code":"11402","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral ","code_information":[{"code":"369","type":"RC"},{"code":"58600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Nerve graft, each additional nerve; multiple strands (cable) (List separately in addition to code for primary procedure) ","code_information":[{"code":"64902","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Synovectomy; intertarsal or tarsometatarsal joint, each ","code_information":[{"code":"28070","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC ","code_information":[{"code":"151","type":"RC"},{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Ureterorrhaphy, suture of ureter (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"50900","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Immunoassay for tumor antigen, qualitative or semiquantitative (eg, bladder tumor antigen) ","code_information":[{"code":"302","type":"RC"},{"code":"86294","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":42.06,"maximum":99.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":42.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":98.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":46.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":46.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":99.72,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"135","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Amniotext patch, per square centimeter ","code_information":[{"code":"Q4247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":585.97,"maximum":3250.85,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3250.85,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3250.85,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":644.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":732.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":585.97,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":732.46,"methodology":"fee schedule"}]}]},{"description":"Photopheresis, extracorporeal ","code_information":[{"code":"36522","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"118","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"130","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"63081","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Rhytidectomy; glabellar frown lines ","code_information":[{"code":"15826","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"59200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer ","code_information":[{"code":"27091","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Repair, primary, open or percutaneous, ruptured Achilles tendon; ","code_information":[{"code":"27650","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion or replacement of percutaneous electrode array, spinal, with integrated neurostimulator, including imaging guidance, when performed ","code_information":[{"code":"0784T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary p ","code_information":[{"code":"20936","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material ","code_information":[{"code":"320","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":529.73,"maximum":588.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":529.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":584.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":588.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":588.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":584.35,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels ","code_information":[{"code":"35571","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC ","code_information":[{"code":"113","type":"RC"},{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Parathyroidectomy or exploration of parathyroid(s); re-exploration ","code_information":[{"code":"481","type":"RC"},{"code":"60502","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":12033.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Injection, oxytetracycline hcl, up to 50 mg ","code_information":[{"code":"J2460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1.04,"maximum":2.52,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2.52,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2.52,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1.14,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.30,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1.04,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.30,"methodology":"fee schedule"}]}]},{"description":"FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY ","code_information":[{"code":"212","type":"RC"},{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft ","code_information":[{"code":"499","type":"RC"},{"code":"66184","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"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":405.53,"maximum":961.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":405.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":947.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":450.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":450.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":961.43,"methodology":"fee schedule"}]}]},{"description":"Drug-induced sleep endoscopy, with dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep-disordered breathing, flexible, diagnostic ","code_information":[{"code":"42975","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy ","code_information":[{"code":"23105","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 1 ","code_information":[{"code":"306","type":"RC"},{"code":"87274","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.71,"maximum":46.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.72,"methodology":"fee schedule"}]}]},{"description":"Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing ","code_information":[{"code":"360","type":"RC"},{"code":"47362","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence ","code_information":[{"code":"81525","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5125.82,"maximum":12152.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5125.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":11977.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5696.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5696.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12152.40,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service ","code_information":[{"code":"52010","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"318","type":"MS-DRG"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; each additional 25 sq cm of harvested skin or part thereo ","code_information":[{"code":"15014","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Clotting inhibitors or anticoagulants; protein C, activity ","code_information":[{"code":"85303","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":22.77,"maximum":53.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":53.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":53.98,"methodology":"fee schedule"}]}]},{"description":"CHEST PAIN ","code_information":[{"code":"113","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) ","code_information":[{"code":"21206","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Atrial septectomy or septostomy; open heart, with inflow occlusion ","code_information":[{"code":"33737","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) ","code_information":[{"code":"322","type":"RC"},{"code":"77063","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":126.03,"maximum":140.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":126.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":139.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":140.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":140.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":139.03,"methodology":"fee schedule"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"148","type":"RC"},{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"481","type":"RC"},{"code":"855","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thoracoscopy, surgical; with control of traumatic hemorrhage ","code_information":[{"code":"32654","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Prolactin ","code_information":[{"code":"309","type":"RC"},{"code":"84146","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.88,"maximum":75.58,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":74.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":75.58,"methodology":"fee schedule"}]}]},{"description":"Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking-induced conformational conversion, qualitative ","code_information":[{"code":"0035U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":889.93,"maximum":2109.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":889.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2079.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":988.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":988.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2109.86,"methodology":"fee schedule"}]}]},{"description":"PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor ºGIST»), gene analysis, targeted sequence analysis (eg, exons 12, 18) ","code_information":[{"code":"81314","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":542.04,"maximum":1285.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":542.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1266.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1285.09,"methodology":"fee schedule"}]}]},{"description":"Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis ","code_information":[{"code":"81415","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":7863.10,"maximum":18642.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7863.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":18374.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8737.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8737.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18642.00,"methodology":"fee schedule"}]}]},{"description":"Kidney function study, non-imaging radioisotopic study ","code_information":[{"code":"349","type":"RC"},{"code":"78725","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":506.50,"maximum":562.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":506.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":558.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":562.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":562.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":558.72,"methodology":"fee schedule"}]}]},{"description":"SYNCOPE AND COLLAPSE ","code_information":[{"code":"207","type":"RC"},{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Angiography, adrenal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"75731","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":799.06,"maximum":887.68,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":799.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":881.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":887.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":887.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":881.46,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement ","code_information":[{"code":"29846","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Repair of fibula nonunion and/or malunion with internal fixation ","code_information":[{"code":"27726","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Nuclear Matrix Protein 22 (NMP22), qualitative ","code_information":[{"code":"86386","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.42,"maximum":92.78,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":22.22,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":38.07,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":92.78,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":92.75,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":22.22,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":22.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":63.57,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":72.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":57.80,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":72.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":55.38,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":21.78,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":21.84,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":17.42,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":22.65,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":22.07,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":21.89,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":21.78,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":21.78,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":22.65,"methodology":"fee schedule"}]}]},{"description":"Sympathectomy; superficial palmar arch ","code_information":[{"code":"499","type":"RC"},{"code":"64823","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"210","type":"RC"},{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Susceptibility studies, antimicrobial agent; enzyme detection (eg, beta lactamase), per enzyme ","code_information":[{"code":"300","type":"RC"},{"code":"87185","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.81,"maximum":18.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":18.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18.52,"methodology":"fee schedule"}]}]},{"description":"Apol1 (apolipoprotein l1) (eg, chronic kidney disease), risk variants ","code_information":[{"code":"0355U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed ","code_information":[{"code":"306","type":"RC"},{"code":"81465","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1539.72,"maximum":3650.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1539.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3597.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3650.40,"methodology":"fee schedule"}]}]},{"description":"Transurethral destruction of prostate tissue; by microwave thermotherapy ","code_information":[{"code":"53850","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique ","code_information":[{"code":"305","type":"RC"},{"code":"87551","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":79.35,"maximum":188.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":79.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":185.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":88.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":88.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":188.14,"methodology":"fee schedule"}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC ","code_information":[{"code":"128","type":"RC"},{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft (includes obtaining graft) ","code_information":[{"code":"27472","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"MINOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":26105.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":30146.760,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":26852.280,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":30146.760,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":30146.760,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":6233.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6532.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":24246.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7258.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":21030.520,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":7158.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7258.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19641.69,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":10706.12,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":7158.83,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":32493.510,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":36103.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":6111.99,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":9928.570,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":11286.980,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":9025.980,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":11286.980,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":20312.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":7018.46,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":5614.77,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":12934.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":23914.320,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":12934.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":7299.20,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":42873.390,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":19225.330,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":12049.680,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":6765.80,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":27664.620,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":7018.46,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":7018.46,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":6505.34,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":7229.01,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"146","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure) ","code_information":[{"code":"38747","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Esophageal recording of atrial electrogram with or without ventricular electrogram(s); with pacing ","code_information":[{"code":"480","type":"RC"},{"code":"93616","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29614.00,"maximum":51885.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"322","type":"RC"},{"code":"77078","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":522.58,"maximum":580.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":522.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":576.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":580.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":580.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":576.47,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine; thoracic, 2 views ","code_information":[{"code":"329","type":"RC"},{"code":"72070","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":171.06,"maximum":190.03,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":171.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":188.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":190.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":190.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":188.70,"methodology":"fee schedule"}]}]},{"description":"Hydroxyindolacetic acid, 5-(HIAA) ","code_information":[{"code":"302","type":"RC"},{"code":"83497","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.22,"maximum":50.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.31,"methodology":"fee schedule"}]}]},{"description":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC ","code_information":[{"code":"115","type":"RC"},{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Irrigation of corpora cavernosa for priapism ","code_information":[{"code":"499","type":"RC"},{"code":"54220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg ","code_information":[{"code":"J7329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.42,"maximum":16.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":8.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12.69,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16.36,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16.36,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":7.42,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":8.43,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":6.74,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":8.43,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5.42,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5.48,"methodology":"fee schedule"}]}]},{"description":"Open treatment of femoral shaft fracture with plate/screws, with or without cerclage ","code_information":[{"code":"27507","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"MSH6 (mutS homolog 6) (eg, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (List separately in addition to code for primary procedure) ","code_information":[{"code":"0160U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":465.34,"maximum":1103.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":465.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1087.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":517.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":517.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1103.23,"methodology":"fee schedule"}]}]},{"description":"Exploration not followed by surgical repair, artery; upper extremity (eg, axillary, brachial, radial, ulnar) ","code_information":[{"code":"35702","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) ","code_information":[{"code":"25415","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Drug assay, definitive, 120 or more drugs and metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS), includes specimen validity and algorithmic analysis descr ","code_information":[{"code":"0328U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":188.24,"maximum":446.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":188.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":439.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":209.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":209.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":446.28,"methodology":"fee schedule"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"144","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1074.37,"maximum":1095.86,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1095.86,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1074.37,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Percutaneous pulmonary artery revascularization by stent placement, initial; abnormal connections, bilateral ","code_information":[{"code":"33903","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC ","code_information":[{"code":"200","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"112","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"87467","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.26,"maximum":64.08,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":20.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":25.83,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":44.26,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":64.08,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":64.06,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":25.83,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":25.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":48.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":55.49,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":44.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":55.49,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":42.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":25.32,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":25.39,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":20.26,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":26.33,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":25.66,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":25.45,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":25.32,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":25.32,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":21.48,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":26.33,"methodology":"fee schedule"}]}]},{"description":"COMPLICATIONS OF TREATMENT WITH CC ","code_information":[{"code":"146","type":"RC"},{"code":"920","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"700","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NONTRAUMATIC STUPOR AND COMA WITHOUT MCC ","code_information":[{"code":"081","type":"MS-DRG"},{"code":"201","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Natural killer (NK) cells, total count ","code_information":[{"code":"300","type":"RC"},{"code":"86357","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":62.07,"maximum":147.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":62.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":145.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":68.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":68.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":147.15,"methodology":"fee schedule"}]}]},{"description":"Drug metabolism, whole blood, pharmacogenomic genotyping of 40 genes and CYP2D6 copy number variant analysis, reported as metabolizer status ","code_information":[{"code":"0516U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"Neuro Muscular Dystrophy Dmd Seq Alys Bld/Saliva ","code_information":[{"code":"0218U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1823.20,"maximum":9705.81,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2324.58,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":3983.46,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":9705.81,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":9702.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2324.58,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2324.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":6652.17,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":7559.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":6047.55,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":7559.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":5794.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":2279.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1823.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2370.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2290.39,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":2279.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":2279.00,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":2370.16,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; transection of vagus nerves, selective or highly selective ","code_information":[{"code":"43652","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH MCC ","code_information":[{"code":"138","type":"RC"},{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"RENAL FAILURE WITH CC ","code_information":[{"code":"148","type":"RC"},{"code":"683","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal fixation, when performed, each ","code_information":[{"code":"28525","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC ","code_information":[{"code":"058","type":"MS-DRG"},{"code":"131","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"134","type":"RC"},{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC ","code_information":[{"code":"423","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SYNCOPE AND COLLAPSE ","code_information":[{"code":"130","type":"RC"},{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"300","type":"RC"},{"code":"87339","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.32,"maximum":62.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.40,"methodology":"fee schedule"}]}]},{"description":"Colostomy or skin level cecostomy; with multiple biopsies (eg, for congenital megacolon) (separate procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"44322","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal ","code_information":[{"code":"360","type":"RC"},{"code":"62294","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension ","code_information":[{"code":"305","type":"RC"},{"code":"86481","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":164.50,"maximum":390.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":164.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":384.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":182.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":182.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":390.00,"methodology":"fee schedule"}]}]},{"description":"Cervical lymphadenectomy (complete) ","code_information":[{"code":"369","type":"RC"},{"code":"38720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral (1 operation) ","code_information":[{"code":"50540","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Vesiculotomy; ","code_information":[{"code":"490","type":"RC"},{"code":"55600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"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":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":137.79,"maximum":326.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":137.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":321.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":153.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":153.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":326.66,"methodology":"fee schedule"}]}]},{"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":"302","type":"RC"},{"code":"81295","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":627.90,"maximum":1488.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":627.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1467.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":697.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":697.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1488.63,"methodology":"fee schedule"}]}]},{"description":"Venous thrombosis imaging, venogram; bilateral ","code_information":[{"code":"340","type":"RC"},{"code":"78458","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":214.08,"maximum":237.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":214.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":236.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":237.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":237.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":236.16,"methodology":"fee schedule"}]}]},{"description":"Fetal contraction stress test ","code_information":[{"code":"499","type":"RC"},{"code":"59020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10010","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"REHABILITATION WITHOUT CC/MCC ","code_information":[{"code":"115","type":"RC"},{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":4005.57,"maximum":9496.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4005.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9360.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4451.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4451.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9496.50,"methodology":"fee schedule"}]}]},{"description":"Cyanide ","code_information":[{"code":"309","type":"RC"},{"code":"82600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.91,"maximum":75.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":74.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":75.66,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, radius; distal third ","code_information":[{"code":"25350","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Excimer laser treatment for psoriasis; 250 sq cm to 500 sq cm ","code_information":[{"code":"369","type":"RC"},{"code":"96921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring ","code_information":[{"code":"360","type":"RC"},{"code":"64530","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Necropsy (autopsy), gross examination only; stillborn or newborn with brain ","code_information":[{"code":"314","type":"RC"},{"code":"88014","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":317.42,"maximum":752.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":317.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":741.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":352.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":352.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":752.54,"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":"324","type":"RC"},{"code":"74183","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":1254.16,"maximum":1393.24,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1254.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1383.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1393.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1393.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1383.48,"methodology":"fee schedule"}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requir ","code_information":[{"code":"360","type":"RC"},{"code":"66989","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":42495.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":35253.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":42495.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Unlisted laparoscopy procedure, maternity care and delivery ","code_information":[{"code":"499","type":"RC"},{"code":"59898","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, with electrocorticography during surgery ","code_information":[{"code":"61539","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Culture, typing; identification by pulse field gel typing ","code_information":[{"code":"303","type":"RC"},{"code":"87152","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.73,"maximum":30.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":29.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":30.19,"methodology":"fee schedule"}]}]},{"description":"Culture, typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene) ","code_information":[{"code":"87153","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":189.77,"maximum":449.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":189.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":443.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":210.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":210.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":449.90,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"127","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Percutaneous balloon valvuloplasty; mitral valve ","code_information":[{"code":"92987","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":50123.00,"maximum":59838.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":50123.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":59838.00,"methodology":"case rate"}]}]},{"description":"Repair, secondary, Achilles tendon, with or without graft ","code_information":[{"code":"27654","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Vestibuloplasty; complex (including ridge extension, muscle repositioning) ","code_information":[{"code":"40845","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds ","code_information":[{"code":"K0862","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":1016.99,"maximum":2222.00,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1296.66,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2222.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1296.66,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1296.66,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1271.24,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1233.10,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1016.99,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1322.09,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1245.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1277.60,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1271.24,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1271.24,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1322.09,"methodology":"fee schedule"}]}]},{"description":"Pharyngolaryngectomy, with radical neck dissection; without reconstruction ","code_information":[{"code":"31390","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary ","code_information":[{"code":"11008","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Closed treatment of acetabulum (hip socket) fracture(s); without manipulation ","code_information":[{"code":"27220","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed ","code_information":[{"code":"87498","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Vasography, vesiculography, or epididymography, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"74440","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":407.55,"maximum":452.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":407.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":449.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":452.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":452.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":449.57,"methodology":"fee schedule"}]}]},{"description":"Marsupialization of pancreatic cyst ","code_information":[{"code":"361","type":"RC"},{"code":"48500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Creatinine; clearance ","code_information":[{"code":"304","type":"RC"},{"code":"82575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.56,"maximum":36.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.89,"methodology":"fee schedule"}]}]},{"description":"Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X) ","code_information":[{"code":"314","type":"RC"},{"code":"88248","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":284.86,"maximum":675.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":284.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":665.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":316.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":316.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":675.36,"methodology":"fee schedule"}]}]},{"description":"Candida species panel (C. albicans, C. glabrata, C. parapsilosis, C. kruseii, C. tropicalis, and C. auris), amplified probe technique with qualitative report of the presence or absence of each species ","code_information":[{"code":"0068U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":234.63,"maximum":556.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":234.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":548.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":260.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":260.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":556.26,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions ","code_information":[{"code":"320","type":"RC"},{"code":"74178","type":"CPT"}],"standard_charges":[{"modifiers":"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":1304.89,"maximum":1449.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1304.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1439.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1449.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1449.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1439.44,"methodology":"fee schedule"}]}]},{"description":"Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) ","code_information":[{"code":"324","type":"RC"},{"code":"77600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2843.24,"maximum":3158.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2843.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3136.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3158.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3158.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3136.42,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination; sternoclavicular joint or joints, minimum of 3 views ","code_information":[{"code":"320","type":"RC"},{"code":"71130","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":52.27,"maximum":58.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":52.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":58.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":58.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":57.66,"methodology":"fee schedule"}]}]},{"description":"Blood typing, serologic; RBC antigens, other than ABO or Rh (D), each ","code_information":[{"code":"44659","type":"CDM"},{"code":"86905","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3.06,"maximum":909.56,"gross_charge":423.00,"discounted_cash":423.00,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":3.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":6.69,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16.31,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16.31,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":3.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":800.42,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":909.56,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":727.67,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":909.56,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":697.20,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":3.83,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":3.06,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":3.98,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3.85,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":3.83,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":3.83,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":3.51,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":3.98,"methodology":"fee schedule"}]}]},{"description":"Salivary gland imaging; ","code_information":[{"code":"342","type":"RC"},{"code":"78230","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":106.19,"maximum":117.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":106.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":117.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":117.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":117.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":117.14,"methodology":"fee schedule"}]}]},{"description":"Bladder instillation of anticarcinogenic agent (including retention time) ","code_information":[{"code":"490","type":"RC"},{"code":"51720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"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":"329","type":"RC"},{"code":"73223","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":513.38,"maximum":570.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":513.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":566.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":570.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":570.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":566.32,"methodology":"fee schedule"}]}]},{"description":"Replantation, thumb (includes distal tip to MP joint), complete amputation ","code_information":[{"code":"20827","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe ","code_information":[{"code":"31628","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) ","code_information":[{"code":"15733","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants, comparative genomic ","code_information":[{"code":"300","type":"RC"},{"code":"81229","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1908.20,"maximum":4524.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1908.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4459.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2120.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2120.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4524.00,"methodology":"fee schedule"}]}]},{"description":"Therapeutic apheresis with selective HDL delipidation and plasma reinfusion ","code_information":[{"code":"0342T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Catheterization, umbilical artery, newborn, for diagnosis or therapy ","code_information":[{"code":"36660","type":"CPT"},{"code":"480","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Muscle, myocutaneous, or fasciocutaneous flap; lower extremity ","code_information":[{"code":"15738","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older ","code_information":[{"code":"36558","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"118","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Gonadotropin; follicle stimulating hormone (FSH) ","code_information":[{"code":"83001","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30.56,"maximum":72.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":71.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":72.46,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion, esophagus, with primary repair; thoracic or abdominal approach ","code_information":[{"code":"360","type":"RC"},{"code":"43101","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75885","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":706.03,"maximum":784.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":706.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":778.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":784.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":784.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":778.83,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NEC ","code_information":[{"code":"004","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH ","code_information":[{"code":"409","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":17873.03,"maximum":18057.28,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":17873.03,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":18057.28,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19»), amplified probe technique ","code_information":[{"code":"112902","type":"CDM"},{"code":"306","type":"RC"},{"code":"87635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.40,"maximum":200.11,"gross_charge":269.50,"discounted_cash":269.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":197.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.11,"methodology":"fee schedule"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"203","type":"RC"},{"code":"869","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) Gamma Knife","code_information":[{"code":"333","type":"RC"},{"code":"61797","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for p ","code_information":[{"code":"499","type":"RC"},{"code":"64484","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code for primary procedure) ","code_information":[{"code":"300","type":"RC"},{"code":"81416","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19740.00,"maximum":46800.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19740.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46128.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21936.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21936.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46800.00,"methodology":"fee schedule"}]}]},{"description":"Laparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to ","code_information":[{"code":"0676T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress ","code_information":[{"code":"E0265","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":143.34,"maximum":313.17,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":182.75,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":313.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":182.75,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":182.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":179.17,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":173.79,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":143.34,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":186.34,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":175.59,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":180.07,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":179.17,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":179.17,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":186.34,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"409","type":"RC"},{"code":"70482","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":806.31,"maximum":895.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":806.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":889.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":895.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":895.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":889.45,"methodology":"fee schedule"}]}]},{"description":"Removal of foreign body, foot; complicated ","code_information":[{"code":"28193","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, ","code_information":[{"code":"52285","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue ","code_information":[{"code":"481","type":"RC"},{"code":"65280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Closure of rectovesical fistula; with colostomy ","code_information":[{"code":"45805","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment ","code_information":[{"code":"L3961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1438.50,"maximum":3142.95,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1834.09,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":3142.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1834.09,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1834.09,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1798.13,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1744.19,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1438.50,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1870.06,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1762.17,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1807.12,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1798.13,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1798.13,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1870.06,"methodology":"fee schedule"}]}]},{"description":"Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax ","code_information":[{"code":"21510","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) ","code_information":[{"code":"25440","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, aortic valve ","code_information":[{"code":"360","type":"RC"},{"code":"93591","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Antepartum care only; 7 or more visits ","code_information":[{"code":"59426","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique ","code_information":[{"code":"307","type":"RC"},{"code":"87800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":71.84,"maximum":170.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":71.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":167.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":79.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":79.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":170.31,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); minimum of 6 views ","code_information":[{"code":"321","type":"RC"},{"code":"72084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":511.89,"maximum":568.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":511.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":564.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":568.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":568.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":564.68,"methodology":"fee schedule"}]}]},{"description":"Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) ","code_information":[{"code":"58180","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Canakinumab injection ","code_information":[{"code":"1311","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":113.28,"maximum":247.51,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":144.44,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":247.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":144.44,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":144.44,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":141.60,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":113.28,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":147.27,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":142.31,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":141.60,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":141.60,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":147.27,"methodology":"fee schedule"}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"160","type":"RC"},{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"409","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":373.88,"maximum":415.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":373.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":412.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":415.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":415.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":412.44,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopy procedure, intestine (except rectum) ","code_information":[{"code":"44238","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA  IPF","code_information":[{"code":"124","type":"RC"},{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1006.04,"maximum":1026.16,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1026.16,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1006.04,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when perf ","code_information":[{"code":"321","type":"RC"},{"code":"77049","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":1250.66,"maximum":1389.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1379.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1389.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1389.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1379.62,"methodology":"fee schedule"}]}]},{"description":"Galactokinase, RBC ","code_information":[{"code":"305","type":"RC"},{"code":"82759","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":35.33,"maximum":83.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":35.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":82.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":39.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":39.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":83.77,"methodology":"fee schedule"}]}]},{"description":"Unlisted procedure, lips ","code_information":[{"code":"40799","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Therapeutic apheresis with selective HDL delipidation and plasma reinfusion ","code_information":[{"code":"0342T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":12033.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC ","code_information":[{"code":"140","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"490","type":"RC"},{"code":"93621","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":51885.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Electroejaculation ","code_information":[{"code":"360","type":"RC"},{"code":"55870","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views ","code_information":[{"code":"321","type":"RC"},{"code":"73503","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":315.49,"maximum":350.48,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":315.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":348.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":350.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":350.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":348.02,"methodology":"fee schedule"}]}]},{"description":"Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) ","code_information":[{"code":"369","type":"RC"},{"code":"51701","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) ","code_information":[{"code":"320","type":"RC"},{"code":"77078","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":59.01,"maximum":65.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":59.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":65.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":65.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":65.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.09,"methodology":"fee schedule"}]}]},{"description":"HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC ","code_information":[{"code":"360","type":"RC"},{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Ciliary body destruction; cryotherapy ","code_information":[{"code":"361","type":"RC"},{"code":"66720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Fasciectomy, plantar fascia; partial (separate procedure) ","code_information":[{"code":"28060","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial ","code_information":[{"code":"41005","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin) ","code_information":[{"code":"43510","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes ","code_information":[{"code":"0434U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"Laparoscopy, surgical; pyeloplasty ","code_information":[{"code":"50544","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown ","code_information":[{"code":"36640","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"CONCUSSION WITH CC ","code_information":[{"code":"089","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Insertion of ocular implant secondary; after enucleation, muscles not attached to implant ","code_information":[{"code":"369","type":"RC"},{"code":"65135","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Proctopexy (eg, for prolapse); with sigmoid resection, abdominal approach ","code_information":[{"code":"45550","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Balloon dilation, ureteral stricture, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code ","code_information":[{"code":"361","type":"RC"},{"code":"50706","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"307","type":"RC"},{"code":"81110","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":201.05,"maximum":476.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":201.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":469.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":476.66,"methodology":"fee schedule"}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle ","code_information":[{"code":"23170","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Repair of encephalocele, skull vault, including cranioplasty ","code_information":[{"code":"499","type":"RC"},{"code":"62120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Radiologic examination, foot; 2 views ","code_information":[{"code":"320","type":"RC"},{"code":"73620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":146.85,"maximum":163.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":146.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":161.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":163.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":163.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":161.99,"methodology":"fee schedule"}]}]},{"description":"Iodine i-123 sodium iodide, diagnostic, per millicurie ","code_information":[{"code":"A9509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.01,"maximum":2549.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.02,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":408.58,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":408.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":2243.67,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":2549.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":2039.47,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":2549.33,"methodology":"fee schedule"}]}]},{"description":"MEDICAL BACK PROBLEMS WITHOUT MCC ","code_information":[{"code":"133","type":"RC"},{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Myelography, thoracic, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"72255","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":215.78,"maximum":239.71,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":215.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":238.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":239.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":239.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":238.03,"methodology":"fee schedule"}]}]},{"description":"Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) ","code_information":[{"code":"369","type":"RC"},{"code":"45317","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculograp ","code_information":[{"code":"0824T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Aldosterone suppression evaluation panel (eg, saline infusion) This panel must include the following: Aldosterone (82088 x 2) Renin (84244 x 2) ","code_information":[{"code":"300","type":"RC"},{"code":"80408","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":206.45,"maximum":489.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":206.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":482.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":229.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":229.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":489.45,"methodology":"fee schedule"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"320","type":"RC"},{"code":"70549","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1823.77,"maximum":2026.02,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1823.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2011.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2026.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2026.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2011.83,"methodology":"fee schedule"}]}]},{"description":"Venous thrombosis imaging, venogram; unilateral ","code_information":[{"code":"340","type":"RC"},{"code":"78457","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":630.52,"maximum":700.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":630.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":695.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":700.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":700.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":695.54,"methodology":"fee schedule"}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT ","code_information":[{"code":"136","type":"RC"},{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar ","code_information":[{"code":"361","type":"RC"},{"code":"62380","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC ","code_information":[{"code":"127","type":"RC"},{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"324","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":1513.27,"maximum":1681.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1513.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1669.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1681.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1681.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1669.30,"methodology":"fee schedule"}]}]},{"description":"Inj thiotepa nos 1 mg ","code_information":[{"code":"847","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":8.43,"maximum":18.42,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":10.75,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":18.42,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":10.75,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":10.75,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":10.54,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":8.43,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":10.96,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10.59,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":10.54,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":10.54,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":10.96,"methodology":"fee schedule"}]}]},{"description":"Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix ","code_information":[{"code":"B4180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":34.34,"maximum":34.69,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":34.34,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":34.69,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC ","code_information":[{"code":"066","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Brain imaging, less than 4 static views; with vascular flow ","code_information":[{"code":"340","type":"RC"},{"code":"78601","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1025.12,"maximum":1138.80,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1025.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1130.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1138.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1138.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1130.82,"methodology":"fee schedule"}]}]},{"description":"Semen analysis; volume, count, motility, and differential ","code_information":[{"code":"305","type":"RC"},{"code":"89320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.25,"maximum":48.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":47.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.01,"methodology":"fee schedule"}]}]},{"description":"CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) ","code_information":[{"code":"309","type":"RC"},{"code":"81231","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":287.56,"maximum":681.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":287.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":671.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":319.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":319.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":681.76,"methodology":"fee schedule"}]}]},{"description":"Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system ","code_information":[{"code":"33262","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34061.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37708.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":37844.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":37844.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37708.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Radiologic examination, osseous survey, infant ","code_information":[{"code":"321","type":"RC"},{"code":"77076","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":168.33,"maximum":187.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":168.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":185.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":187.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":187.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":185.69,"methodology":"fee schedule"}]}]},{"description":"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC ","code_information":[{"code":"069","type":"MS-DRG"},{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC  IPF","code_information":[{"code":"144","type":"RC"},{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1091.82,"maximum":1113.66,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1113.66,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1091.82,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Unlisted laparoscopy procedure, rectum ","code_information":[{"code":"45499","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Valvuloplasty, femoral vein ","code_information":[{"code":"34501","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Cytopathology, evaluation of fine needle aspirate; interpretation and report ","code_information":[{"code":"310","type":"RC"},{"code":"88173","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.86,"maximum":194.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":194.06,"methodology":"fee schedule"}]}]},{"description":"Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, fe ","code_information":[{"code":"0802T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body ","code_information":[{"code":"25101","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic ","code_information":[{"code":"369","type":"RC"},{"code":"38205","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of femoral fracture, proximal end, head; without manipulation ","code_information":[{"code":"27267","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm ","code_information":[{"code":"11311","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC ","code_information":[{"code":"144","type":"RC"},{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) ","code_information":[{"code":"25446","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"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":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC ","code_information":[{"code":"155","type":"RC"},{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each ","code_information":[{"code":"304","type":"RC"},{"code":"86971","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":479.12,"maximum":1135.91,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":479.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1119.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":532.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":532.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1135.91,"methodology":"fee schedule"}]}]},{"description":"URINARY STONES WITHOUT MCC ","code_information":[{"code":"113","type":"RC"},{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Neurology Alzheimer Disease Cell Aggregation ","code_information":[{"code":"0206U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3644.33,"maximum":8640.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3644.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8516.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4049.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4049.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8640.06,"methodology":"fee schedule"}]}]},{"description":"Microsomal antibodies (eg, thyroid or liver-kidney), each ","code_information":[{"code":"306","type":"RC"},{"code":"86376","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.93,"maximum":56.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.75,"methodology":"fee schedule"}]}]},{"description":" Behavioral Health Treatment/Services Intensive Outpatient Services - Psychiatric  Adult","code_information":[{"code":"905","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":540.00,"maximum":600.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":540.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":600.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":600.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":600.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":600.00,"methodology":"case rate"}]}]},{"description":"Tonsillectomy and adenoidectomy; age 12 or over ","code_information":[{"code":"42821","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Incision of conjunctiva, drainage of cyst ","code_information":[{"code":"68020","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Radiologic examination, knee, arthrography, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"73580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":558.46,"maximum":620.39,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":558.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":616.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":620.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":620.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":616.05,"methodology":"fee schedule"}]}]},{"description":"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC ","code_information":[{"code":"069","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Carcinoembryonic antigen (CEA) ","code_information":[{"code":"305","type":"RC"},{"code":"82378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.19,"maximum":73.94,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":72.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":73.94,"methodology":"fee schedule"}]}]},{"description":"Antibody; respiratory syncytial virus ","code_information":[{"code":"302","type":"RC"},{"code":"86756","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.14,"maximum":61.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.97,"methodology":"fee schedule"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC ","code_information":[{"code":"057","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new 180 day implantable sensor, including system activation ","code_information":[{"code":"490","type":"RC"},{"code":"G0309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) ","code_information":[{"code":"307","type":"RC"},{"code":"85460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.72,"maximum":30.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":29.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":30.15,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of ","code_information":[{"code":"33951","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps ","code_information":[{"code":"31032","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) ","code_information":[{"code":"300","type":"RC"},{"code":"G9143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":198.58,"maximum":470.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":198.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":464.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":220.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":220.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":470.81,"methodology":"fee schedule"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch ","code_information":[{"code":"369","type":"RC"},{"code":"64450","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion ","code_information":[{"code":"69745","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Urography, antegrade, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"74425","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":573.88,"maximum":637.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":573.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":633.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":637.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":637.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":633.06,"methodology":"fee schedule"}]}]},{"description":"Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s) ","code_information":[{"code":"305","type":"RC"},{"code":"G9143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":198.58,"maximum":470.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":198.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":464.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":220.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":220.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":470.81,"methodology":"fee schedule"}]}]},{"description":"Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch ","code_information":[{"code":"33641","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Liver imaging; with vascular flow ","code_information":[{"code":"349","type":"RC"},{"code":"78202","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":894.87,"maximum":994.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":894.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":987.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":994.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":994.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":987.15,"methodology":"fee schedule"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC ","code_information":[{"code":"207","type":"RC"},{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Operculectomy, excision pericoronal tissues ","code_information":[{"code":"369","type":"RC"},{"code":"41821","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); INCARCERATED OR STRANGULATED ","code_information":[{"code":"49655","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Antibody; Chlamydia, IgM ","code_information":[{"code":"309","type":"RC"},{"code":"86632","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.86,"maximum":49.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":48.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":49.45,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"084","type":"MS-DRG"},{"code":"111","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Immunoassay for infectious agent antibody, quantitative, not otherwise specified ","code_information":[{"code":"305","type":"RC"},{"code":"86317","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.66,"maximum":58.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.46,"methodology":"fee schedule"}]}]},{"description":"Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic removal of bone ","code_information":[{"code":"481","type":"RC"},{"code":"65112","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (eg, Jones type procedure) ","code_information":[{"code":"28760","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar ","code_information":[{"code":"22224","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Dilation of urethral stricture by passage of filiform and follower, male; subsequent ","code_information":[{"code":"361","type":"RC"},{"code":"53621","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC ","code_information":[{"code":"057","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Wedging of clubfoot cast ","code_information":[{"code":"29750","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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; sacral ","code_information":[{"code":"63011","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Arthroplasty, interphalangeal joint; with prosthetic implant, each joint ","code_information":[{"code":"26536","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); cytomegalovirus ","code_information":[{"code":"300","type":"RC"},{"code":"87910","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":423.51,"maximum":1004.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":423.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":989.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1004.05,"methodology":"fee schedule"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"131","type":"RC"},{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone) EEG","code_information":[{"code":"861","type":"RC"},{"code":"95801","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":488.00,"maximum":1032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":488.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1032.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":542.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":542.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1032.00,"methodology":"case rate"}]}]},{"description":"BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC ","code_information":[{"code":"211","type":"RC"},{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Frenulotomy of penis ","code_information":[{"code":"360","type":"RC"},{"code":"54164","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"SEIZURES WITH MCC ","code_information":[{"code":"100","type":"MS-DRG"},{"code":"112","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy, indirect; with biopsy ","code_information":[{"code":"31510","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Computed tomography, lumbar spine; without contrast material ","code_information":[{"code":"324","type":"RC"},{"code":"72131","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":236.13,"maximum":262.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":236.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":260.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":262.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":262.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":260.48,"methodology":"fee schedule"}]}]},{"description":"Cortisol; total ","code_information":[{"code":"303","type":"RC"},{"code":"82533","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.81,"maximum":63.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63.57,"methodology":"fee schedule"}]}]},{"description":"Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft ","code_information":[{"code":"66180","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Suture of each additional major peripheral nerve (List separately in addition to code for primary procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"64859","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators ","code_information":[{"code":"321","type":"RC"},{"code":"77610","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":352.45,"maximum":391.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":352.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":388.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":391.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":391.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":388.79,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant ","code_information":[{"code":"369","type":"RC"},{"code":"52441","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Carboxyhemoglobin; qualitative ","code_information":[{"code":"304","type":"RC"},{"code":"82376","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.15,"maximum":54.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":54.87,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; femoral-femoral ","code_information":[{"code":"35558","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE ","code_information":[{"code":"325","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":20957.75,"maximum":21173.81,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":20957.75,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":21173.81,"methodology":"fee schedule"}]}]},{"description":"Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery ","code_information":[{"code":"59618","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Hematology, red blood cell (RBC) adhesion to endothelial/subendothelial adhesion molecules, functional assessment, whole blood with algorithmic analysis and result reported as an RBC adhesion index; n ","code_information":[{"code":"0304U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3414.69,"maximum":8095.62,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3414.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7979.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3794.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3794.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8095.62,"methodology":"fee schedule"}]}]},{"description":"Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed ","code_information":[{"code":"360","type":"RC"},{"code":"50250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Carboxyhemoglobin; quantitative ","code_information":[{"code":"34349","type":"CDM"},{"code":"82375","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.86,"maximum":52.48,"gross_charge":473.00,"discounted_cash":473.00,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":12.57,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":21.53,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":52.48,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":52.46,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":12.57,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":12.57,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":39.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":45.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":36.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":45.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":34.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":12.32,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12.36,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12.81,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12.49,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.38,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":12.32,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":12.32,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11.30,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12.81,"methodology":"fee schedule"}]}]},{"description":"Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); with fluoroscopic or CT guidance ","code_information":[{"code":"499","type":"RC"},{"code":"62329","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy ","code_information":[{"code":"360","type":"RC"},{"code":"50976","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Biliary endoscopy, intraoperative (choledochoscopy) (List separately in addition to code for primary procedure) ","code_information":[{"code":"47550","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC ","code_information":[{"code":"083","type":"MS-DRG"},{"code":"127","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to cod ","code_information":[{"code":"22208","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC ","code_information":[{"code":"069","type":"MS-DRG"},{"code":"164","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tenodesis; of proximal interphalangeal joint, each joint ","code_information":[{"code":"26471","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Discography, lumbar, radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"72295","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":374.29,"maximum":415.80,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":374.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":412.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":415.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":415.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":412.89,"methodology":"fee schedule"}]}]},{"description":"Clot retraction ","code_information":[{"code":"306","type":"RC"},{"code":"85170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.81,"maximum":63.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63.57,"methodology":"fee schedule"}]}]},{"description":"Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen, radiologic supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"75902","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":353.27,"maximum":392.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":353.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":389.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":392.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":392.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":389.70,"methodology":"fee schedule"}]}]},{"description":"Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic ","code_information":[{"code":"39545","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"115","type":"RC"},{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WIT ","code_information":[{"code":"145","type":"RC"},{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"158","type":"RC"},{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, sinuses, paranasal, complete, minimum of 3 views ","code_information":[{"code":"409","type":"RC"},{"code":"70220","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":143.20,"maximum":159.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":143.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":157.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":159.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":159.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":157.97,"methodology":"fee schedule"}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"144","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of wrist prosthesis; complicated, including total wrist ","code_information":[{"code":"25251","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal ","code_information":[{"code":"44625","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Silica ","code_information":[{"code":"304","type":"RC"},{"code":"84285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.47,"maximum":98.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":41.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":96.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":46.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":46.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":98.32,"methodology":"fee schedule"}]}]},{"description":"Tracheoplasty; cervical ","code_information":[{"code":"31750","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Inj tedizolid phosphate ","code_information":[{"code":"1662","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1.57,"maximum":3.43,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2.00,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":3.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2.00,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1.96,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1.57,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2.04,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1.97,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1.96,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1.96,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":2.04,"methodology":"fee schedule"}]}]},{"description":"Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral ","code_information":[{"code":"54901","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Elastase, pancreatic (EL-1), fecal; quantitative ","code_information":[{"code":"304","type":"RC"},{"code":"82653","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.79,"maximum":89.58,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":37.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":88.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":41.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":89.58,"methodology":"fee schedule"}]}]},{"description":"ENDOCRINE DISORDERS WITH CC ","code_information":[{"code":"121","type":"RC"},{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary ","code_information":[{"code":"31633","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Blood bank physician services; difficult cross match and/or evaluation of irregular antibody(s), interpretation and written report ","code_information":[{"code":"309","type":"RC"},{"code":"86077","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.58,"maximum":96.21,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":94.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":96.21,"methodology":"fee schedule"}]}]},{"description":"Autologous blood or component, collection processing and storage; intra- or postoperative salvage ","code_information":[{"code":"300","type":"RC"},{"code":"86891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1079.37,"maximum":2558.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1079.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2522.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1199.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2558.98,"methodology":"fee schedule"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC ","code_information":[{"code":"125","type":"RC"},{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"URINARY STONES WITHOUT MCC ","code_information":[{"code":"149","type":"RC"},{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"147","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) ","code_information":[{"code":"67900","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19023.00,"maximum":22929.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) ","code_information":[{"code":"369","type":"RC"},{"code":"44207","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"SMPD1 (sphingomyelin phosphodiesterase 1, acid lysosomal) (eg, Niemann-Pick disease, Type A) gene analysis, common variants (eg, R496L, L302P, fsP330) ","code_information":[{"code":"81330","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":77.31,"maximum":183.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":77.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":180.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":85.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":85.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":183.30,"methodology":"fee schedule"}]}]},{"description":"Walker, with trunk support, adjustable or fixed height, any type ","code_information":[{"code":"E0140","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":26.54,"maximum":58.00,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":33.84,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":58.00,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":33.84,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":33.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":33.18,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":32.18,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":26.54,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":34.51,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":32.52,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":33.35,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":33.18,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":33.18,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":34.51,"methodology":"fee schedule"}]}]},{"description":"Growth hormone, human (HGH) (somatotropin) ","code_information":[{"code":"83003","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.42,"maximum":65.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.01,"methodology":"fee schedule"}]}]},{"description":"Cast supplies, long leg cast, pediatric (0-10 years), plaster ","code_information":[{"code":"Q4031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":14.42,"maximum":31.51,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":31.51,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":18.03,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":17.49,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":14.42,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":18.75,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":17.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18.12,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":18.03,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":18.03,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":18.75,"methodology":"fee schedule"}]}]},{"description":"Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) ","code_information":[{"code":"29851","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique ","code_information":[{"code":"37116","type":"CDM"},{"code":"87496","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.07,"maximum":149.45,"gross_charge":2012.50,"discounted_cash":2012.50,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":31.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":35.79,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":61.33,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":149.45,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":149.40,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":35.79,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":35.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":113.81,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":129.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":103.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":129.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":99.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":35.09,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":35.19,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":28.07,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":36.49,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":35.55,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":35.27,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":35.09,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":35.09,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":32.17,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":36.49,"methodology":"fee schedule"}]}]},{"description":"Thrombolysis, coronary; by intravenous infusion ","code_information":[{"code":"790","type":"RC"},{"code":"92977","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"RENAL FAILURE WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction ","code_information":[{"code":"22315","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motionºs» and/or ejection fractionºs», when performed); multiple studies at rest and stress (exercis ","code_information":[{"code":"342","type":"RC"},{"code":"78431","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":437.36,"maximum":485.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":437.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":482.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":485.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":485.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":482.46,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette ","code_information":[{"code":"304","type":"RC"},{"code":"85461","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.40,"maximum":36.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":35.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.50,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation ","code_information":[{"code":"29825","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) ","code_information":[{"code":"324","type":"RC"},{"code":"70336","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1380.50,"maximum":1533.59,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1380.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1522.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1533.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1533.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1522.85,"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":[{"setting":"outpatient","minimum":1200.70,"maximum":1333.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1200.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1324.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1333.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1333.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1324.51,"methodology":"fee schedule"}]}]},{"description":"Upper extremity addition, locking elbow, forearm counterbalance ","code_information":[{"code":"L6693","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2676.10,"maximum":5846.95,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":3412.03,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":5846.95,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":3412.03,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":3412.03,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":3345.13,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3244.78,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":2676.10,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":3478.94,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3278.23,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":3361.86,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":3345.13,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":3345.13,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":3478.94,"methodology":"fee schedule"}]}]},{"description":" Audiology General Classification  ","code_information":[{"code":"470","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":780.00,"maximum":1653.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":780.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1653.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":867.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":867.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1653.00,"methodology":"case rate"}]}]},{"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":"361","type":"RC"},{"code":"47541","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Injection, isavuconazonium ","code_information":[{"code":"09456","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":0.97,"maximum":0.98,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.97,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.98,"methodology":"fee schedule"}]}]},{"description":"Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"27892","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Computed tomography, cervical spine; with contrast material ","code_information":[{"code":"321","type":"RC"},{"code":"72126","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":288.35,"maximum":320.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":288.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":318.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":320.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":320.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":318.09,"methodology":"fee schedule"}]}]},{"description":"Inj, fylnetra, 0.5 mg ","code_information":[{"code":"9118","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":110.37,"maximum":241.15,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":140.72,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":241.15,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":140.72,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":140.72,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":137.97,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":110.37,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":143.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":138.65,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":137.97,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":137.97,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":143.48,"methodology":"fee schedule"}]}]},{"description":"Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy ","code_information":[{"code":"64763","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC ","code_information":[{"code":"207","type":"RC"},{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair blood vessel with graft other than vein; upper extremity ","code_information":[{"code":"35266","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair initial femoral hernia, any age; reducible ","code_information":[{"code":"369","type":"RC"},{"code":"49550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure) ","code_information":[{"code":"33277","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Decompressive fasciotomy, hand (excludes 26035) ","code_information":[{"code":"26037","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) ","code_information":[{"code":"56515","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic lymphadenectomy) ","code_information":[{"code":"55862","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen and pelvis; with contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"74177","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":434.33,"maximum":482.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":434.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":479.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":482.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":482.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":479.12,"methodology":"fee schedule"}]}]},{"description":"Skin test; unlisted antigen, each ","code_information":[{"code":"302","type":"RC"},{"code":"86486","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.58,"maximum":96.21,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":94.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":96.21,"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":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":423.95,"maximum":470.96,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":423.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":467.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":470.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":470.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":467.66,"methodology":"fee schedule"}]}]},{"description":"Red cell antigen (Yt blood group) genotyping (YT), gene analysis, ACHE (acetylcholinesterase (Cartwright blood group)) exon 2 ","code_information":[{"code":"0201U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"Repair round window fistula ","code_information":[{"code":"490","type":"RC"},{"code":"69667","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) ","code_information":[{"code":"322","type":"RC"},{"code":"77605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4908.65,"maximum":5452.99,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4908.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5414.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5452.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5452.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5414.79,"methodology":"fee schedule"}]}]},{"description":"Venography, renal, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75831","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":616.23,"maximum":684.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":616.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":679.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":684.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":684.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":679.78,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia ","code_information":[{"code":"26705","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Transection or repositioning of aberrant renal vessels (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"50100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"NEUROSES EXCEPT DEPRESSIVE  IPF","code_information":[{"code":"154","type":"RC"},{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1143.49,"maximum":1166.36,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1166.36,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1143.49,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"Lengthening of hamstring tendon; multiple tendons, bilateral ","code_information":[{"code":"27395","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Magnetic resonance imaging, breast, without contrast material; bilateral ","code_information":[{"code":"77047","type":"CPT"},{"code":"85349","type":"CDM"}],"standard_charges":[{"setting":"outpatient","minimum":576.50,"maximum":720.63,"gross_charge":3124.75,"discounted_cash":3124.75,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":634.15,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":720.63,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":576.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":720.63,"methodology":"fee schedule"}]}]},{"description":"CHEST PAIN ","code_information":[{"code":"200","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair) ","code_information":[{"code":"46761","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Maple syrup urine disease monitoring by patient-collected blood card sample, quantitative measurement of allo-isoleucine, leucine, isoleucine, and valine, liquid chromatography with tandem mass spectr ","code_information":[{"code":"0381U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":72.58,"maximum":172.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":72.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":169.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":80.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":80.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":172.07,"methodology":"fee schedule"}]}]},{"description":"PMS2 (postmeiotic segregation increased 2 ºS. cerevisiae») (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants ","code_information":[{"code":"307","type":"RC"},{"code":"81319","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":334.76,"maximum":793.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":334.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":782.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":372.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":372.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":793.65,"methodology":"fee schedule"}]}]},{"description":"Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy ","code_information":[{"code":"306","type":"RC"},{"code":"81507","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1307.78,"maximum":3100.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1307.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3055.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1453.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1453.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3100.50,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) ","code_information":[{"code":"323","type":"RC"},{"code":"72159","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1372.84,"maximum":1525.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1372.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1514.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1525.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1525.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1514.40,"methodology":"fee schedule"}]}]},{"description":"Trabeculotomy by laser, including optical coherence tomography (OCT) guidance ","code_information":[{"code":"0730T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Arytenoidectomy or arytenoidopexy, external approach ","code_information":[{"code":"31400","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Chemodenervation of trunk muscle(s); 6 or more muscles ","code_information":[{"code":"361","type":"RC"},{"code":"64647","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Artificial insemination; intra-cervical ","code_information":[{"code":"499","type":"RC"},{"code":"58321","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, age 12 years or older ","code_information":[{"code":"31552","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Leukocyte phagocytosis ","code_information":[{"code":"86344","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.31,"maximum":44.23,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":9.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":10.60,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":18.16,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":44.23,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":44.22,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":10.60,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":10.60,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":30.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":34.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":27.57,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":34.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":26.42,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":10.39,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":10.42,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":8.31,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":10.81,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":10.53,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":10.44,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":10.39,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":10.39,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":9.53,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":10.81,"methodology":"fee schedule"}]}]},{"description":"COAGULATION DISORDERS ","code_information":[{"code":"144","type":"RC"},{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair of meningocele; larger than 5 cm diameter ","code_information":[{"code":"361","type":"RC"},{"code":"63702","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC ","code_information":[{"code":"123","type":"RC"},{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician ","code_information":[{"code":"409","type":"RC"},{"code":"77331","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":101.16,"maximum":112.37,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":101.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":111.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":112.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":112.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":111.59,"methodology":"fee schedule"}]}]},{"description":"Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with repair of subpulmonic obstruction ","code_information":[{"code":"33777","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH CC ","code_information":[{"code":"138","type":"RC"},{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair) ","code_information":[{"code":"46761","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"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":"33883","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"TRAUMATIC INJURY WITH MCC ","code_information":[{"code":"113","type":"RC"},{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure ","code_information":[{"code":"22844","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Gonadotropin, chorionic (hCG); quantitative ","code_information":[{"code":"302","type":"RC"},{"code":"84702","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.76,"maximum":58.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.70,"methodology":"fee schedule"}]}]},{"description":"Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss) ","code_information":[{"code":"43502","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Gastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13C) spirulina substrate, analysis of each specimen by gas isotope ratio mass spectrometry, reported as rat ","code_information":[{"code":"0106U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1438.54,"maximum":3410.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1438.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3361.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1598.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1598.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3410.51,"methodology":"fee schedule"}]}]},{"description":"Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater ","code_information":[{"code":"21931","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation ","code_information":[{"code":"20816","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Open treatment of mandibular condylar fracture ","code_information":[{"code":"21465","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthrodesis, wrist; with autograft (includes obtaining graft) ","code_information":[{"code":"25825","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC ","code_information":[{"code":"204","type":"RC"},{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Oncology (colorectal), quantitative assessment of three urine metabolites (ascorbic acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (LCMS/MS) using multiple r ","code_information":[{"code":"0002U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":41.13,"maximum":97.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":41.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":96.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":45.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":45.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":97.50,"methodology":"fee schedule"}]}]},{"description":"Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy) ","code_information":[{"code":"50130","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Oncology (prostate), augmentative algorithmic analysis of digitized whole-slide imaging of histologic features for microsatellite instability (MSI) status, formalin-fixed paraffin-embedded (FFPE) tiss ","code_information":[{"code":"0512U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1161.78,"maximum":2754.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1161.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2714.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1291.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1291.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2754.38,"methodology":"fee schedule"}]}]},{"description":"Endoscopic submucosal dissection (esd), including endoscopy or colonoscopy, mucosal closure, when performed ","code_information":[{"code":"490","type":"RC"},{"code":"C9779","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"155","type":"RC"},{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radical resection of tumor; talus or calcaneus ","code_information":[{"code":"27647","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) ","code_information":[{"code":"323","type":"RC"},{"code":"G0130","type":"HCPCS"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":55.77,"maximum":61.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":61.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":61.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.52,"methodology":"fee schedule"}]}]},{"description":"Percutaneous implantation or replacement of integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator, including analysis, prog ","code_information":[{"code":"0587T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Complement; functional activity, each component ","code_information":[{"code":"49438","type":"CDM"},{"code":"86161","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.60,"maximum":51.11,"gross_charge":450.75,"discounted_cash":450.75,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":12.24,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":20.97,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":51.11,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":51.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":12.24,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":12.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":38.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":44.21,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":35.37,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":44.21,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":33.89,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":12.00,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12.04,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9.60,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12.48,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.06,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":12.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":12.00,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11.00,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12.48,"methodology":"fee schedule"}]}]},{"description":"NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis ","code_information":[{"code":"81192","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":341.02,"maximum":808.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":341.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":796.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":808.51,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm ","code_information":[{"code":"12045","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated ","code_information":[{"code":"302","type":"RC"},{"code":"80055","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":78.65,"maximum":186.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":78.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":183.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":87.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":87.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":186.46,"methodology":"fee schedule"}]}]},{"description":"Urethrocystography, voiding, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"74455","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":451.29,"maximum":501.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":451.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":497.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":501.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":501.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":497.83,"methodology":"fee schedule"}]}]},{"description":"Flexible endoscopic evaluation of swallowing by cine or video recording; interpretation and report only ","code_information":[{"code":"92613","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.44,"maximum":34.79,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":34.44,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":34.79,"methodology":"fee schedule"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"114","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OSTEOMYELITIS WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna ","code_information":[{"code":"25455","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications ","code_information":[{"code":"400","type":"RC"},{"code":"77301","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":2152.63,"maximum":2391.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2152.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2374.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2391.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2391.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2374.60,"methodology":"fee schedule"}]}]},{"description":"ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY  IPF","code_information":[{"code":"136","type":"RC"},{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1073.89,"maximum":1073.89,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1073.89,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) ","code_information":[{"code":"21194","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Arthrodesis, great toe; metatarsophalangeal joint ","code_information":[{"code":"28750","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Oxalate ","code_information":[{"code":"306","type":"RC"},{"code":"83945","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.77,"maximum":56.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.35,"methodology":"fee schedule"}]}]},{"description":"Somatostatin ","code_information":[{"code":"307","type":"RC"},{"code":"84307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30.07,"maximum":71.29,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":70.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":33.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":33.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":71.29,"methodology":"fee schedule"}]}]},{"description":"NON-MALIGNANT BREAST DISORDERS WITH CC/MCC ","code_information":[{"code":"142","type":"RC"},{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, innominate, subclavian artery, by thoracic incision ","code_information":[{"code":"35022","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, a ","code_information":[{"code":"311","type":"RC"},{"code":"81552","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12791.52,"maximum":30326.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12791.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":29890.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14214.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14214.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":30326.40,"methodology":"fee schedule"}]}]},{"description":"Reimplantation of an anomalous pulmonary artery ","code_information":[{"code":"33788","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Ketosteroids, 17- (17-KS); total ","code_information":[{"code":"309","type":"RC"},{"code":"83586","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.06,"maximum":49.92,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":49.92,"methodology":"fee schedule"}]}]},{"description":"Reptilase test ","code_information":[{"code":"304","type":"RC"},{"code":"85635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.20,"maximum":38.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":38.41,"methodology":"fee schedule"}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"214","type":"RC"},{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Fibrinolytic factors and inhibitors; plasminogen, antigenic assay ","code_information":[{"code":"85421","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":16.75,"maximum":39.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":39.70,"methodology":"fee schedule"}]}]},{"description":"Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication ","code_information":[{"code":"55000","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC  IPF","code_information":[{"code":"154","type":"RC"},{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1222.84,"maximum":1247.30,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1247.30,"methodology":"fee schedule","additional_payer_notes":"Days 4. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1222.84,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Protein, total, except by refractometry; serum, plasma or whole blood ","code_information":[{"code":"84155","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6.04,"maximum":14.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14.31,"methodology":"fee schedule"}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC ","code_information":[{"code":"200","type":"RC"},{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty ","code_information":[{"code":"43842","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closed treatment of distal fibular fracture (lateral malleolus); without manipulation ","code_information":[{"code":"27786","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Plastic operation of penis for injury ","code_information":[{"code":"361","type":"RC"},{"code":"54440","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only ","code_information":[{"code":"0862T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC ","code_information":[{"code":"152","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":6598.90,"maximum":6666.93,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":6598.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":6666.93,"methodology":"fee schedule"}]}]},{"description":"Urinary undiversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy with ureteroureterostomy or ureteroneocystostomy) ","code_information":[{"code":"490","type":"RC"},{"code":"50830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endogra ","code_information":[{"code":"34844","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CCND1/IGH (t(11;14)) (eg, mantle cell lymphoma) translocation analysis, major breakpoint, qualitative and quantitative, if performed ","code_information":[{"code":"306","type":"RC"},{"code":"81168","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":341.02,"maximum":808.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":341.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":796.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":808.51,"methodology":"fee schedule"}]}]},{"description":"OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"750","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":12656.85,"maximum":12787.33,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12656.85,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":12787.33,"methodology":"fee schedule"}]}]},{"description":"HLA Class II typing, low resolution (eg, antigen equivalents); one antigen equivalent, each ","code_information":[{"code":"304","type":"RC"},{"code":"81377","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":155.85,"maximum":369.49,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":155.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":364.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":173.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":173.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":369.49,"methodology":"fee schedule"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"122","type":"RC"},{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1893.53,"maximum":1893.53,"payers_information":[{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1893.53,"methodology":"per diem"}]}]},{"description":"Repair of high imperforate anus with rectourethral or rectovaginal fistula; perineal or sacroperineal approach ","code_information":[{"code":"46740","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy; fibula ","code_information":[{"code":"27707","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"209","type":"RC"},{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Mercury, quantitative ","code_information":[{"code":"83825","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":26.75,"maximum":63.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63.41,"methodology":"fee schedule"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC ","code_information":[{"code":"211","type":"RC"},{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bypass graft, with vein; axillary-axillary ","code_information":[{"code":"35518","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":" Behavioral Health Treatment/Services Individual Therapy  ","code_information":[{"code":"914","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":90.00,"maximum":90.00,"payers_information":[{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":43.90,"standard_charge_algorithm":"Reimbursement will be 43.9% of billable gross charges.","estimated_amount":295.300,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Centene Granite State Health","plan_name":"BAV","standard_charge_dollar":90.00,"methodology":"case rate"},{"payer_name":"Granite State Health","plan_name":"MGMCDBH","standard_charge_dollar":90.00,"methodology":"case rate"}]}]},{"description":"Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) ","code_information":[{"code":"68420","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Exploration not followed by surgical repair, artery; neck (eg, carotid, subclavian) ","code_information":[{"code":"35701","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) ","code_information":[{"code":"15201","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions ","code_information":[{"code":"74178","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":980.41,"maximum":1225.53,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1078.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1225.53,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":980.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1225.53,"methodology":"fee schedule"}]}]},{"description":"Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 ºCDK1», IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score fo ","code_information":[{"code":"0012M","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.20,"maximum":2964.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2921.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2964.00,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope ","code_information":[{"code":"43180","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Nephrectomy, partial ","code_information":[{"code":"481","type":"RC"},{"code":"50240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure ","code_information":[{"code":"305","type":"RC"},{"code":"88377","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE WITH CC/MCC ","code_information":[{"code":"145","type":"RC"},{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"25025","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"DIGESTIVE MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"201","type":"RC"},{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft) ","code_information":[{"code":"26844","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"156","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1280.71,"maximum":1280.71,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1280.71,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"Antibody; encephalitis, Eastern equine ","code_information":[{"code":"86652","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.55,"maximum":56.15,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":11.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":13.45,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":23.05,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":56.15,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":56.13,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":13.45,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":13.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":42.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":48.59,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":38.88,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":48.59,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":37.25,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":13.19,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":13.23,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":10.55,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":13.72,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":13.37,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":13.26,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":13.19,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":13.19,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":12.09,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":13.72,"methodology":"fee schedule"}]}]},{"description":"Graft for facial nerve paralysis; free muscle flap by microsurgical technique ","code_information":[{"code":"15842","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITH CC/MCC ","code_information":[{"code":"052","type":"MS-DRG"},{"code":"142","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"409","type":"RC"},{"code":"74175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1611.44,"maximum":1790.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1611.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1777.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1790.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1790.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1777.60,"methodology":"fee schedule"}]}]},{"description":"Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) ","code_information":[{"code":"481","type":"RC"},{"code":"64575","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":63632.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36318.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Ethylene glycol ","code_information":[{"code":"306","type":"RC"},{"code":"82693","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.51,"maximum":58.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.11,"methodology":"fee schedule"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"156","type":"MS-DRG"},{"code":"208","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CONCUSSION WITH MCC ","code_information":[{"code":"088","type":"MS-DRG"},{"code":"146","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tissue transglutaminase, each immunoglobulin (Ig) class ","code_information":[{"code":"301","type":"RC"},{"code":"86364","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.97,"maximum":44.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":44.97,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing ","code_information":[{"code":"400","type":"RC"},{"code":"70555","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":594.13,"maximum":660.02,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":594.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":655.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":660.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":660.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":655.40,"methodology":"fee schedule"}]}]},{"description":"Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test ","code_information":[{"code":"307","type":"RC"},{"code":"89330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.08,"maximum":40.48,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":40.48,"methodology":"fee schedule"}]}]},{"description":"Removal of lens material; pars plana approach, with or without vitrectomy ","code_information":[{"code":"499","type":"RC"},{"code":"66852","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) ","code_information":[{"code":"58660","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis ","code_information":[{"code":"304","type":"RC"},{"code":"81216","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":304.52,"maximum":721.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":721.97,"methodology":"fee schedule"}]}]},{"description":"BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure) ","code_information":[{"code":"0138U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":770.40,"maximum":1826.49,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":770.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1800.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":856.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":856.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1826.49,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, knee, arthrography, radiological supervision and interpretation ","code_information":[{"code":"73580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":308.06,"maximum":1717.48,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1717.48,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1717.48,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":338.87,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":385.08,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":308.06,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":385.08,"methodology":"fee schedule"}]}]},{"description":"Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) ","code_information":[{"code":"21180","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Arthrotomy, wrist joint; with synovectomy ","code_information":[{"code":"25105","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Acute venous thrombosis imaging, peptide ","code_information":[{"code":"342","type":"RC"},{"code":"78456","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1465.36,"maximum":1627.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1465.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1616.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1627.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1627.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1616.46,"methodology":"fee schedule"}]}]},{"description":"HEADACHES WITHOUT MCC ","code_information":[{"code":"103","type":"MS-DRG"},{"code":"147","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, wrist, arthrography, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"73115","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":136.26,"maximum":151.37,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":136.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":150.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":151.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":151.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":150.31,"methodology":"fee schedule"}]}]},{"description":"Application of short arm splint (forearm to hand); dynamic ","code_information":[{"code":"29126","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Magnetic resonance angiography, head; without contrast material(s) ","code_information":[{"code":"323","type":"RC"},{"code":"70544","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":853.24,"maximum":947.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":853.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":941.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":947.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":947.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":941.22,"methodology":"fee schedule"}]}]},{"description":"CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES ","code_information":[{"code":"018","type":"MS-DRG"},{"code":"119","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens ","code_information":[{"code":"V2103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":32.66,"maximum":71.35,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":41.64,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":71.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":41.64,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":41.64,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":40.82,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":39.60,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":32.66,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":42.45,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":40.00,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":41.02,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":40.82,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":40.82,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":42.45,"methodology":"fee schedule"}]}]},{"description":"Escharotomy; initial incision ","code_information":[{"code":"16035","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) ","code_information":[{"code":"20700","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"084","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":4769.00,"maximum":12033.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST PROCEDURES WITHOUT CC/MCC ","code_information":[{"code":"165","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal, non-biodegradable drug delivery implant ","code_information":[{"code":"11982","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint ","code_information":[{"code":"26545","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral ","code_information":[{"code":"324","type":"RC"},{"code":"77065","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":459.67,"maximum":510.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":459.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":507.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":510.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":510.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":507.07,"methodology":"fee schedule"}]}]},{"description":"Thiethylperazine maleate, 10 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 ","code_information":[{"code":"Q0174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.70,"maximum":1.69,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1.69,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":0.77,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":0.87,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.70,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":0.87,"methodology":"fee schedule"}]}]},{"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":"81493","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1727.25,"maximum":4095.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1727.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4036.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1919.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1919.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4095.00,"methodology":"fee schedule"}]}]},{"description":"AR (androgen receptor), full sequence analyis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions ","code_information":[{"code":"0230U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":495.72,"maximum":1175.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":495.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1158.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":550.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":550.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1175.27,"methodology":"fee schedule"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY ","code_information":[{"code":"450","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) ","code_information":[{"code":"369","type":"RC"},{"code":"50389","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Excimer laser treatment for psoriasis; over 500 sq cm ","code_information":[{"code":"499","type":"RC"},{"code":"96922","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Revise fallopian tube(s) ","code_information":[{"code":"T0014","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":671.76,"maximum":678.69,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":671.76,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":678.69,"methodology":"fee schedule"}]}]},{"description":"Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation ","code_information":[{"code":"76948","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":189.18,"maximum":236.48,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":208.10,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":236.48,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":189.18,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":236.48,"methodology":"fee schedule"}]}]},{"description":"Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) ","code_information":[{"code":"33365","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm ","code_information":[{"code":"11401","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope ","code_information":[{"code":"31526","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC ","code_information":[{"code":"208","type":"RC"},{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES ","code_information":[{"code":"018","type":"MS-DRG"},{"code":"158","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cm ","code_information":[{"code":"25076","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"329","type":"RC"},{"code":"72197","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":1247.12,"maximum":1385.42,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1247.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1375.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1385.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1385.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1375.71,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique ","code_information":[{"code":"309","type":"RC"},{"code":"87563","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"DIABETES WITH MCC ","code_information":[{"code":"130","type":"RC"},{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"481","type":"RC"},{"code":"62325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) ","code_information":[{"code":"324","type":"RC"},{"code":"75774","type":"CPT"}],"standard_charges":[{"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":263.99,"maximum":293.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":263.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":291.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":293.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":293.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":291.21,"methodology":"fee schedule"}]}]},{"description":"Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips ","code_information":[{"code":"E0114","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":44.84,"maximum":97.97,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":57.17,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":97.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":57.17,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":57.17,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":56.05,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":54.37,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":44.84,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":58.29,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":54.93,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":56.33,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":56.05,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":56.05,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":58.29,"methodology":"fee schedule"}]}]},{"description":"Russell viper venom time (includes venom); diluted ","code_information":[{"code":"303","type":"RC"},{"code":"85613","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.76,"maximum":37.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37.36,"methodology":"fee schedule"}]}]},{"description":"DIGESTIVE MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"119","type":"RC"},{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm ","code_information":[{"code":"12006","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); without bypass ","code_information":[{"code":"33310","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant ","code_information":[{"code":"307","type":"RC"},{"code":"81186","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of a ","code_information":[{"code":"33965","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head ","code_information":[{"code":"28288","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg ","code_information":[{"code":"J7508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.55,"maximum":1.53,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1.53,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1.53,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":0.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":0.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":0.63,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":0.79,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.55,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.56,"methodology":"fee schedule"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventri ","code_information":[{"code":"360","type":"RC"},{"code":"61863","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Revision of colostomy; simple (release of superficial scar) (separate procedure) ","code_information":[{"code":"44340","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Diverticulectomy of hypopharynx or esophagus, with or without myotomy; thoracic approach ","code_information":[{"code":"43135","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing ","code_information":[{"code":"22310","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation; with insertion of transurethral ultrasound ","code_information":[{"code":"361","type":"RC"},{"code":"55882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":983.56,"maximum":2331.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":983.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2298.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1092.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1092.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2331.85,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC ","code_information":[{"code":"191","type":"MS-DRG"},{"code":"208","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure ","code_information":[{"code":"499","type":"RC"},{"code":"67840","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Antibody; Toxoplasma, IgM ","code_information":[{"code":"301","type":"RC"},{"code":"86778","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.70,"maximum":56.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":55.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.20,"methodology":"fee schedule"}]}]},{"description":"Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score ","code_information":[{"code":"307","type":"RC"},{"code":"81519","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":6371.09,"maximum":15104.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6371.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14887.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15104.70,"methodology":"fee schedule"}]}]},{"description":"Cardiac shunt detection ","code_information":[{"code":"340","type":"RC"},{"code":"78428","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":707.52,"maximum":785.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":707.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":780.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":785.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":785.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":780.48,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, femoral neck (separate procedure) ","code_information":[{"code":"27161","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Open treatment of humeral shaft fracture with plate/screws, with or without cerclage ","code_information":[{"code":"24515","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH CC ","code_information":[{"code":"155","type":"RC"},{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any method (eg, excision, isolation via stapling, oversewing, ligation, plication, clip ","code_information":[{"code":"33268","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_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":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk ","code_information":[{"code":"490","type":"RC"},{"code":"G0121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"0652T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis ","code_information":[{"code":"301","type":"RC"},{"code":"89261","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.86,"maximum":194.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":194.06,"methodology":"fee schedule"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"125","type":"RC"},{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngeal reinnervation by neuromuscular pedicle ","code_information":[{"code":"31590","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"MAJOR CHEST TRAUMA WITH CC ","code_information":[{"code":"154","type":"RC"},{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repositioning of previously placed central venous catheter under fluoroscopic guidance ","code_information":[{"code":"36597","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8238.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femur ","code_information":[{"code":"27495","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel ","code_information":[{"code":"20526","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon ","code_information":[{"code":"26145","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component ","code_information":[{"code":"23334","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Inj., meropenem, vaborbact ","code_information":[{"code":"09178","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2.12,"maximum":2.14,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2.12,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2.14,"methodology":"fee schedule"}]}]},{"description":"Repair of component(s) of a multi-component, inflatable penile prosthesis ","code_information":[{"code":"54408","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Fracture nasal inferior turbinate(s), therapeutic ","code_information":[{"code":"30930","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC ","code_information":[{"code":"146","type":"RC"},{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, thorax, diagnostic; without contrast material ","code_information":[{"code":"329","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":442.55,"maximum":491.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":442.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":488.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":491.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":491.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":488.19,"methodology":"fee schedule"}]}]},{"description":"CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants ","code_information":[{"code":"301","type":"RC"},{"code":"81222","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":715.69,"maximum":1696.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":715.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1672.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":795.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":795.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1696.77,"methodology":"fee schedule"}]}]},{"description":"PLEURAL EFFUSION WITH CC ","code_information":[{"code":"142","type":"RC"},{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) ","code_information":[{"code":"321","type":"RC"},{"code":"74182","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":409.45,"maximum":454.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":409.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":451.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":454.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":454.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":451.67,"methodology":"fee schedule"}]}]},{"description":"REHABILITATION WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SEPTIC ARTHRITIS WITHOUT CC/MCC ","code_information":[{"code":"145","type":"RC"},{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Tlso, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapul ","code_information":[{"code":"L0484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2135.58,"maximum":4665.97,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2722.86,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":4665.97,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2722.86,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2722.86,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":2669.47,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2589.39,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":2135.58,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2776.25,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2616.08,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2682.82,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":2669.47,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":2669.47,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":2776.25,"methodology":"fee schedule"}]}]},{"description":"Collection of venous blood by venipuncture ","code_information":[{"code":"36415","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection procedure for discography, each level; lumbar ","code_information":[{"code":"361","type":"RC"},{"code":"62290","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only ","code_information":[{"code":"329","type":"RC"},{"code":"77431","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":554.71,"maximum":616.22,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":554.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":611.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":616.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":616.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":611.91,"methodology":"fee schedule"}]}]},{"description":"Esophagoscopy, flexible, transoral; with endoscopic mucosal resection ","code_information":[{"code":"43211","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors ","code_information":[{"code":"25115","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Necropsy (autopsy), gross and microscopic; without CNS ","code_information":[{"code":"88020","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":45.66,"maximum":45.67,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":45.67,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":45.66,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, teeth; partial examination, less than full mouth ","code_information":[{"code":"400","type":"RC"},{"code":"70310","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":171.21,"maximum":190.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":171.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":188.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":190.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":190.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":188.87,"methodology":"fee schedule"}]}]},{"description":"SEPTIC ARTHRITIS WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, upper extremity; with contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"73201","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":778.30,"maximum":864.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":778.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":858.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":864.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":864.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":858.55,"methodology":"fee schedule"}]}]},{"description":"Cetuximab injection ","code_information":[{"code":"09215","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":76.02,"maximum":76.80,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":76.02,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":76.80,"methodology":"fee schedule"}]}]},{"description":"Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies ","code_information":[{"code":"44111","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Alpha-1-antitrypsin; total ","code_information":[{"code":"302","type":"RC"},{"code":"82103","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":22.11,"maximum":52.42,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":22.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.42,"methodology":"fee schedule"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"674","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Complex dynamic pharyngeal and speech evaluation by cine or video recording ","code_information":[{"code":"324","type":"RC"},{"code":"70371","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":211.41,"maximum":234.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":211.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":233.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":234.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":234.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":233.21,"methodology":"fee schedule"}]}]},{"description":"U-tube hepaticoenterostomy ","code_information":[{"code":"361","type":"RC"},{"code":"47802","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC ","code_information":[{"code":"157","type":"RC"},{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation ","code_information":[{"code":"24582","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"211","type":"RC"},{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Hydroxyproline; total ","code_information":[{"code":"300","type":"RC"},{"code":"83505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.97,"maximum":94.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":39.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":93.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":44.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":44.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":94.77,"methodology":"fee schedule"}]}]},{"description":"Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger ","code_information":[{"code":"26160","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Reproductive medicine, RNA gene expression profile 238 genes by next-generation sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation ","code_information":[{"code":"0253U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5197.25,"maximum":12321.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5197.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":12144.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5775.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5775.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12321.74,"methodology":"fee schedule"}]}]},{"description":"Oncology (urothelial carcinoma),DNA,quantitative methylationspecific PCR of 2 genes (ONECUT2,VIM),algorithmic analysis reported as positive or negative ","code_information":[{"code":"0465U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3188.03,"maximum":7558.24,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3188.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7449.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3542.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3542.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":7558.24,"methodology":"fee schedule"}]}]},{"description":"Inj. inebilizumab-cdon, 1 ","code_information":[{"code":"9394","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":396.44,"maximum":866.16,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":505.46,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":866.16,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":505.46,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":505.46,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":495.55,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":396.44,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":515.37,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":498.02,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":495.55,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":495.55,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":515.37,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing ","code_information":[{"code":"323","type":"RC"},{"code":"71275","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1485.36,"maximum":1650.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1485.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1638.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1650.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1650.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1638.52,"methodology":"fee schedule"}]}]},{"description":"Application of body cast, shoulder to hips; including 1 thigh ","code_information":[{"code":"29044","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck ","code_information":[{"code":"23174","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH MCC ","code_information":[{"code":"204","type":"RC"},{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT ","code_information":[{"code":"148","type":"RC"},{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism ","code_information":[{"code":"309","type":"RC"},{"code":"87798","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":" Room & Board - Private (One Bed) Obstetrics (OB)  ","code_information":[{"code":"112","type":"RC"}],"standard_charges":[{"setting":"inpatient","payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":46.90,"standard_charge_algorithm":"Reimbursement will be 46.9% of billable gross charges.","estimated_amount":17730.030,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"818","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Myelography, 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation ","code_information":[{"code":"324","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":453.04,"maximum":503.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":453.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":499.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":503.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":503.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":499.75,"methodology":"fee schedule"}]}]},{"description":"Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes ","code_information":[{"code":"97032","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.52,"maximum":25.17,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":14.69,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":25.17,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":14.69,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":14.69,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":14.40,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":13.96,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":11.52,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":14.98,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14.10,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":14.47,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":14.40,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":14.40,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":14.98,"methodology":"fee schedule"}]}]},{"description":"Glutamate dehydrogenase ","code_information":[{"code":"305","type":"RC"},{"code":"82965","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.63,"maximum":51.29,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.29,"methodology":"fee schedule"}]}]},{"description":"FRACTURES OF FEMUR WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus ºbowleg» or genu valgus ºknock-knee»); before epiphyseal closure ","code_information":[{"code":"27455","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromas ","code_information":[{"code":"0419T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0277U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1000.44,"maximum":2371.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1000.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2337.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1111.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2371.86,"methodology":"fee schedule"}]}]},{"description":"Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony def ","code_information":[{"code":"490","type":"RC"},{"code":"69719","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"DIABETES WITH MCC ","code_information":[{"code":"121","type":"RC"},{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance ","code_information":[{"code":"360","type":"RC"},{"code":"61751","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, requiring hospitalization ","code_information":[{"code":"42971","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed ","code_information":[{"code":"323","type":"RC"},{"code":"77778","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":2362.29,"maximum":2624.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2362.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2605.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2624.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2624.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2605.88,"methodology":"fee schedule"}]}]},{"description":"Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar ","code_information":[{"code":"490","type":"RC"},{"code":"63170","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"214","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator ","code_information":[{"code":"0408T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, mandible; partial, less than 4 views ","code_information":[{"code":"70100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":116.31,"maximum":405.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":405.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":405.00,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":127.94,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":145.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":116.31,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":145.39,"methodology":"fee schedule"}]}]},{"description":"Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach ","code_information":[{"code":"39000","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, soft tissue neck; without contrast material ","code_information":[{"code":"320","type":"RC"},{"code":"70490","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":305.06,"maximum":338.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":305.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":336.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":336.51,"methodology":"fee schedule"}]}]},{"description":"AFTERCARE WITHOUT CC/MCC ","code_information":[{"code":"115","type":"RC"},{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC ","code_information":[{"code":"154","type":"RC"},{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) ","code_information":[{"code":"45398","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE ","code_information":[{"code":"141","type":"RC"},{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; ","code_information":[{"code":"361","type":"RC"},{"code":"58957","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid processºes»), includes internal fixation, when performed ","code_information":[{"code":"24685","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Prothrombin time; substitution, plasma fractions, each ","code_information":[{"code":"85611","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6.48,"maximum":15.37,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":15.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15.37,"methodology":"fee schedule"}]}]},{"description":"Foot, arch support, removable, premolded, metatarsal, each ","code_information":[{"code":"L3050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":44.27,"maximum":96.73,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":56.45,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":96.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":56.45,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":56.45,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":55.34,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":53.68,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":44.27,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":57.55,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":54.23,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":55.62,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":55.34,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":55.34,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":57.55,"methodology":"fee schedule"}]}]},{"description":"HEART FAILURE AND SHOCK WITHOUT CC/MCC ","code_information":[{"code":"116","type":"RC"},{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical ","code_information":[{"code":"499","type":"RC"},{"code":"63280","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"114","type":"RC"},{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC ","code_information":[{"code":"134","type":"RC"},{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Donor hepatectomy (including cold preservation), from cadaver donor ","code_information":[{"code":"47133","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Repair of defect with autograft; radius AND ulna ","code_information":[{"code":"25426","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Leg strap, h style, each ","code_information":[{"code":"K0039","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":49.32,"maximum":107.76,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":62.88,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":107.76,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":62.88,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":62.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":61.65,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":59.80,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":49.32,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":64.12,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":60.42,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":61.96,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":61.65,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":61.65,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":64.12,"methodology":"fee schedule"}]}]},{"description":"Antibody; Rickettsia ","code_information":[{"code":"307","type":"RC"},{"code":"86757","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.83,"maximum":75.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":74.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":75.47,"methodology":"fee schedule"}]}]},{"description":"Susceptibility studies, antimicrobial agent; macrobroth dilution method, each agent ","code_information":[{"code":"301","type":"RC"},{"code":"87188","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.92,"maximum":25.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":25.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":25.90,"methodology":"fee schedule"}]}]},{"description":"Repair of anomalous coronary artery from pulmonary artery origin; with construction of intrapulmonary artery tunnel (Takeuchi procedure) ","code_information":[{"code":"33505","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH CC ","code_information":[{"code":"197","type":"MS-DRG"},{"code":"207","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, finger(s), minimum of 2 views ","code_information":[{"code":"324","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":165.92,"maximum":184.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":165.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":183.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":184.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":184.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":183.03,"methodology":"fee schedule"}]}]},{"description":"Keratoprosthesis ","code_information":[{"code":"481","type":"RC"},{"code":"65770","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75741","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":663.99,"maximum":737.62,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":663.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":732.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":737.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":737.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":732.45,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, soft tissue neck; with contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"70491","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":640.03,"maximum":711.01,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":640.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":706.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":711.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":711.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":706.03,"methodology":"fee schedule"}]}]},{"description":"Epididymectomy; bilateral ","code_information":[{"code":"361","type":"RC"},{"code":"54861","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Fat or lipids, feces; quantitative ","code_information":[{"code":"82710","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.64,"maximum":65.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.52,"methodology":"fee schedule"}]}]},{"description":"ENDOCRINE DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, ribs, bilateral; 3 views ","code_information":[{"code":"400","type":"RC"},{"code":"71110","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":157.18,"maximum":174.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":157.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":173.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":174.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":174.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":173.39,"methodology":"fee schedule"}]}]},{"description":"Skin test; candida ","code_information":[{"code":"309","type":"RC"},{"code":"86485","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.58,"maximum":96.21,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":94.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":96.21,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique ","code_information":[{"code":"304","type":"RC"},{"code":"87661","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Biopsy, vertebral body, open; thoracic ","code_information":[{"code":"20250","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision ","code_information":[{"code":"31085","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC ","code_information":[{"code":"152","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"71555","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":1330.80,"maximum":1478.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1330.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1468.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1478.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1478.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1468.02,"methodology":"fee schedule"}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm ","code_information":[{"code":"11421","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Closure of ureterocutaneous fistula ","code_information":[{"code":"499","type":"RC"},{"code":"50920","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint ","code_information":[{"code":"26676","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair ","code_information":[{"code":"40814","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"SKIN ULCERS WITH CC ","code_information":[{"code":"208","type":"RC"},{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Dome and mouthpiece, used with small volume ultrasonic nebulizer ","code_information":[{"code":"A7016","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":7.30,"maximum":15.96,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":9.31,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":15.96,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":9.31,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":9.31,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":9.13,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":8.86,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":7.30,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9.50,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":8.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9.18,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":9.13,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":9.13,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":9.50,"methodology":"fee schedule"}]}]},{"description":"Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disrupti ","code_information":[{"code":"33883","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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":1254.26,"maximum":1254.26,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1254.26,"methodology":"fee schedule","additional_payer_notes":"Days 6. "}]}]},{"description":"Scrotoplasty; simple ","code_information":[{"code":"369","type":"RC"},{"code":"55175","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) (List separately in addition to code for primary procedure) ","code_information":[{"code":"33141","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed ","code_information":[{"code":"61715","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) ","code_information":[{"code":"20650","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"PNEUMOTHORAX WITH MCC ","code_information":[{"code":"135","type":"RC"},{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection, pralatrexate, 1 mg ","code_information":[{"code":"J9307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":356.53,"maximum":1002.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":390.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":448.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":433.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":356.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":433.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":535.44,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1002.45,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1002.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":454.62,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":516.55,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":413.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":516.55,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":362.56,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":366.29,"methodology":"fee schedule"}]}]},{"description":"Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs ","code_information":[{"code":"21812","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical ","code_information":[{"code":"481","type":"RC"},{"code":"63300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Computed tomography, cervical spine; without contrast material ","code_information":[{"code":"329","type":"RC"},{"code":"72125","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":447.80,"maximum":497.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":447.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":493.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":497.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":497.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":493.97,"methodology":"fee schedule"}]}]},{"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":"369","type":"RC"},{"code":"49617","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"description":"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"118","type":"RC"},{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"PLEURAL EFFUSION WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC ","code_information":[{"code":"054","type":"MS-DRG"},{"code":"134","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":[{"setting":"outpatient","minimum":1698.77,"maximum":1887.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1698.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1873.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1887.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1887.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1873.93,"methodology":"fee schedule"}]}]},{"description":"Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption ","code_information":[{"code":"43847","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Cholecystectomy with exploration of common duct; with choledochoenterostomy ","code_information":[{"code":"47612","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"329","type":"RC"},{"code":"77307","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":782.26,"maximum":869.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":782.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":862.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":869.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":869.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":862.92,"methodology":"fee schedule"}]}]},{"description":"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC ","code_information":[{"code":"201","type":"RC"},{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thrombectomy, direct or with catheter; axillary and subclavian vein, by arm incision ","code_information":[{"code":"34490","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Osteotomy and transfer of greater trochanter of femur (separate procedure) ","code_information":[{"code":"27140","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"154","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1008.96,"maximum":1029.14,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1029.14,"methodology":"fee schedule","additional_payer_notes":"Days 3. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1008.96,"methodology":"fee schedule","additional_payer_notes":"Days 3. "}]}]},{"description":"Immunoassay for infectious agent antibody, quantitative, not otherwise specified ","code_information":[{"code":"86317","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":24.66,"maximum":58.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.46,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, soft tissue neck; without contrast material ","code_information":[{"code":"322","type":"RC"},{"code":"70490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":787.86,"maximum":875.23,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":787.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":869.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":875.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":875.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":869.10,"methodology":"fee schedule"}]}]},{"description":"Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy ","code_information":[{"code":"33243","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Reptilase test ","code_information":[{"code":"85635","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.88,"maximum":41.93,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":10.05,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":17.22,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":41.93,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":41.92,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":10.05,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":10.05,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":31.93,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":36.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":29.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":36.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":27.81,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":9.85,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":9.87,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":7.88,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":10.24,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":9.98,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":9.90,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":9.85,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":9.85,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":9.03,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":10.24,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, temporomandibular joint, open and closed mouth; unilateral ","code_information":[{"code":"322","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":134.41,"maximum":149.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":134.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":148.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":149.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":149.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":148.27,"methodology":"fee schedule"}]}]},{"description":"PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence ","code_information":[{"code":"81307","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":541.20,"maximum":2881.11,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":602.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":690.03,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1182.45,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2881.11,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2880.23,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":690.03,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":690.03,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1974.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":2243.88,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1795.16,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":2243.88,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":1720.00,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":676.50,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":541.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":703.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":679.88,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":676.50,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":676.50,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":620.28,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":703.56,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical therapy, by intra-articular administration ","code_information":[{"code":"341","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":207.60,"maximum":230.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":207.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":229.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":230.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":230.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":229.01,"methodology":"fee schedule"}]}]},{"description":"Gastrostomy, open; neonatal, for feeding ","code_information":[{"code":"43831","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Wheelchair accessory, cylinder tank carrier, each ","code_information":[{"code":"E2208","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":64.75,"maximum":141.48,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":82.56,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":141.48,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":82.56,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":82.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":80.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":78.51,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":64.75,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":84.18,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":79.32,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":81.34,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":80.94,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":80.94,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":84.18,"methodology":"fee schedule"}]}]},{"description":"Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, a ","code_information":[{"code":"341","type":"RC"},{"code":"73435","type":"CDM"},{"code":"78453","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":1143.50,"maximum":1270.30,"gross_charge":4179.50,"discounted_cash":4179.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1143.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1261.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1270.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1270.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1261.40,"methodology":"fee schedule"}]}]},{"description":"Brachytherapy isodose plan; intermediate (calculationºs» made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) ","code_information":[{"code":"329","type":"RC"},{"code":"77317","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":1202.61,"maximum":1335.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1202.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1326.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1335.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1335.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1326.61,"methodology":"fee schedule"}]}]},{"description":"Release of encircling material (posterior segment) ","code_information":[{"code":"369","type":"RC"},{"code":"67115","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Transanal insertion of endoluminal temporary colorectal anastomosis protection device, including vacuum anchoring component and flexible sheath connected to external vacuum source and monitoring ","code_information":[{"code":"0967T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil ","code_information":[{"code":"0978T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Excision of carotid body tumor; with excision of carotid artery ","code_information":[{"code":"60605","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"REPAIR UMBILICAL HERNIA, YOUNGER THAN AGE 5 YEARS; INCARCERATED OR STRANGULATED ","code_information":[{"code":"369","type":"RC"},{"code":"49582","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Surgery of intracranial arteriovenous malformation; supratentorial, complex ","code_information":[{"code":"361","type":"RC"},{"code":"61682","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Suction assisted lipectomy; trunk ","code_information":[{"code":"15877","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"FOOT PROCEDURES WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"135","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"320","type":"RC"},{"code":"73202","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":286.61,"maximum":318.39,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":286.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":316.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":318.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":318.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":316.16,"methodology":"fee schedule"}]}]},{"description":"Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) ","code_information":[{"code":"27177","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands ","code_information":[{"code":"42509","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Targeted genomic sequence analysis panel, cholangiocarcinoma and non-small cell lung neoplasia, DNA and RNA analysis, 1-23 genes, interrogation for sequence variants and rearrangements, reported as pr ","code_information":[{"code":"0022U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3207.75,"maximum":7605.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3207.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7495.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3564.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3564.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":7605.00,"methodology":"fee schedule"}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis ","code_information":[{"code":"44202","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural r ","code_information":[{"code":"0338T","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"PULMONARY EMBOLISM WITHOUT MCC ","code_information":[{"code":"176","type":"MS-DRG"},{"code":"208","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"145","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC ","code_information":[{"code":"098","type":"MS-DRG"},{"code":"206","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ALLOGENEIC BONE MARROW TRANSPLANT ","code_information":[{"code":"014","type":"MS-DRG"},{"code":"204","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment ","code_information":[{"code":"L3935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":189.14,"maximum":413.24,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":241.15,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":413.24,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":241.15,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":241.15,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":236.42,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":229.33,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":189.14,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":245.88,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":231.69,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":237.60,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":236.42,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":236.42,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":245.88,"methodology":"fee schedule"}]}]},{"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":"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":1131.21,"maximum":1256.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1131.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1247.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1256.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1256.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1247.85,"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":"307","type":"RC"},{"code":"87631","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":234.63,"maximum":556.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":234.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":548.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":260.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":260.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":556.26,"methodology":"fee schedule"}]}]},{"description":"EXTRAOCULAR PROCEDURES EXCEPT ORBIT ","code_information":[{"code":"115","type":"MS-DRG"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) ","code_information":[{"code":"22846","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Injection(s), anesthetic agent(s) and/or steroid; plantar common digital nerve(s) (eg, Morton's neuroma) ","code_information":[{"code":"361","type":"RC"},{"code":"64455","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) ","code_information":[{"code":"0267T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Cystography, minimum of 3 views, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"74430","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":213.57,"maximum":237.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":213.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":235.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":237.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":237.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":235.59,"methodology":"fee schedule"}]}]},{"description":"Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separat ","code_information":[{"code":"15774","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"43266","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation ","code_information":[{"code":"23675","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia ","code_information":[{"code":"26705","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"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":"400","type":"RC"},{"code":"73223","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":513.38,"maximum":570.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":513.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":566.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":570.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":570.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":566.32,"methodology":"fee schedule"}]}]},{"description":"Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution (List separately in addition to primary procedure) ","code_information":[{"code":"309","type":"RC"},{"code":"86826","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":60.09,"maximum":142.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":60.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":140.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":66.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":66.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":142.47,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITH CC ","code_information":[{"code":"157","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence ","code_information":[{"code":"302","type":"RC"},{"code":"81351","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1055.84,"maximum":2503.22,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1055.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2467.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1173.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1173.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2503.22,"methodology":"fee schedule"}]}]},{"description":"Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator) ","code_information":[{"code":"33226","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"MEDICAL BACK PROBLEMS WITH MCC ","code_information":[{"code":"551","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":7566.67,"maximum":7644.67,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":7566.67,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":7644.67,"methodology":"fee schedule"}]}]},{"description":"Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm ","code_information":[{"code":"12036","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) ","code_information":[{"code":"21208","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Water chamber for humidifier, used with positive airway pressure device, replacement, each ","code_information":[{"code":"A7046","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":12.98,"maximum":28.35,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":16.54,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":28.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":16.54,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":16.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":16.22,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":15.73,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":12.98,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":16.87,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":15.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":16.30,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":16.22,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":16.22,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":16.87,"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 visceral vessels (mesenteri ","code_information":[{"code":"35092","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by leg incision ","code_information":[{"code":"34201","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Oncology (ovarian) biochemical assays of five proteins (apolipoprotein A-1, CA 125 II, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a ","code_information":[{"code":"0003U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1562.75,"maximum":3705.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1562.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3651.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1736.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1736.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3705.00,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of pelvis and hip area; superficial ","code_information":[{"code":"27040","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"130","type":"RC"},{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC ","code_information":[{"code":"066","type":"MS-DRG"},{"code":"128","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC ","code_information":[{"code":"086","type":"MS-DRG"},{"code":"150","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) ","code_information":[{"code":"27122","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":26605.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Radiologic examination, teeth; partial examination, less than full mouth ","code_information":[{"code":"324","type":"RC"},{"code":"70310","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":171.21,"maximum":190.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":171.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":188.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":190.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":190.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":188.87,"methodology":"fee schedule"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed ","code_information":[{"code":"360","type":"RC"},{"code":"43210","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Radiologic examination, pharynx and/or cervical esophagus, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study ","code_information":[{"code":"321","type":"RC"},{"code":"74210","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":139.76,"maximum":155.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":139.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":154.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":155.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":155.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":154.17,"methodology":"fee schedule"}]}]},{"description":"Flexible endoscopic evaluation of swallowing by cine or video recording; ","code_information":[{"code":"92612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":158.71,"maximum":346.77,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":202.36,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":346.77,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":202.36,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":202.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":198.39,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":192.44,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":158.71,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":206.33,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":194.42,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":199.38,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":198.39,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":198.39,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":206.33,"methodology":"fee schedule"}]}]},{"description":"Injection, melphalan hydrochloride, not otherwise specified, 50 mg ","code_information":[{"code":"J9245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":147.81,"maximum":358.56,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":202.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":233.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":225.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":185.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":225.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":278.04,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":358.56,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":358.56,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":162.61,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":184.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":147.81,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":184.76,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":152.39,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":153.96,"methodology":"fee schedule"}]}]},{"description":"CELLULITIS WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple ","code_information":[{"code":"369","type":"RC"},{"code":"38570","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":14872.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":14872.70,"methodology":"case rate"}]}]},{"description":"Cold agglutinin; screen ","code_information":[{"code":"302","type":"RC"},{"code":"86156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":13.28,"maximum":31.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":13.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":31.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":14.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":14.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":31.47,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, knee, any technique ","code_information":[{"code":"27580","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"81187","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":109.60,"maximum":583.46,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":122.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":139.74,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":239.46,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":583.46,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":583.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":139.74,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":139.74,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":399.89,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":454.42,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":363.54,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":454.42,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":348.32,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":109.60,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":142.48,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":137.68,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":137.00,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":125.62,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":142.48,"methodology":"fee schedule"}]}]},{"description":"OTITIS MEDIA AND URI WITHOUT MCC ","code_information":[{"code":"140","type":"RC"},{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC ","code_information":[{"code":"167","type":"RC"},{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) ","code_information":[{"code":"24066","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Gradient pressure wrap with adjustable straps, foot, each ","code_information":[{"code":"A6587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":57.00,"maximum":124.54,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":72.67,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":124.54,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":72.67,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":72.67,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":71.25,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":69.11,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":57.00,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":74.10,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":69.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":71.61,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":71.25,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":71.25,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":74.10,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITHOUT CC/MCC ","code_information":[{"code":"136","type":"RC"},{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Prolactin ","code_information":[{"code":"305","type":"RC"},{"code":"84146","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.88,"maximum":75.58,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":74.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":75.58,"methodology":"fee schedule"}]}]},{"description":"Testosterone; bioavailable, direct measurement (eg, differential precipitation) ","code_information":[{"code":"300","type":"RC"},{"code":"84410","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.36,"maximum":199.99,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":197.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":93.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":93.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":199.99,"methodology":"fee schedule"}]}]},{"description":"Replace trilateral socket brim ","code_information":[{"code":"L4010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":604.86,"maximum":1321.53,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":771.19,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1321.53,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":771.19,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":771.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":756.07,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":733.39,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":604.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":786.31,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":740.95,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":759.85,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":756.07,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":756.07,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":786.31,"methodology":"fee schedule"}]}]},{"description":"SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"451","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":22388.62,"maximum":22619.43,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":22388.62,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":22619.43,"methodology":"fee schedule"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"062","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC ","code_information":[{"code":"146","type":"RC"},{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC ","code_information":[{"code":"259","type":"MS-DRG"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"329","type":"RC"},{"code":"72127","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":734.56,"maximum":816.02,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":734.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":810.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":816.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":816.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":810.30,"methodology":"fee schedule"}]}]},{"description":" Room & Board - Semi-private (Two Beds) Psychiatric  Mental Health Inpatient (Adult/Geriatric)","code_information":[{"code":"124","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":1274.00,"maximum":1274.00,"payers_information":[{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_dollar":1274.00,"methodology":"per diem"}]}]},{"description":"Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon ","code_information":[{"code":"25310","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Reduction of overcorrection of ptosis ","code_information":[{"code":"499","type":"RC"},{"code":"67909","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Vasopressin (antidiuretic hormone, ADH) ","code_information":[{"code":"309","type":"RC"},{"code":"84588","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":55.83,"maximum":132.37,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":55.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":130.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":62.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":62.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":132.37,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive ","code_information":[{"code":"29898","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral ","code_information":[{"code":"27027","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Removal, non-biodegradable drug delivery implant ","code_information":[{"code":"11982","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"DIGESTIVE MALIGNANCY WITH CC ","code_information":[{"code":"125","type":"RC"},{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC ","code_information":[{"code":"360","type":"RC"},{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius ","code_information":[{"code":"25151","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"SYNCOPE AND COLLAPSE ","code_information":[{"code":"146","type":"RC"},{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation ","code_information":[{"code":"361","type":"RC"},{"code":"61697","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral ","code_information":[{"code":"409","type":"RC"},{"code":"77066","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":585.75,"maximum":650.71,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":585.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":646.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":650.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":650.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":646.15,"methodology":"fee schedule"}]}]},{"description":"BEHAVIORAL AND DEVELOPMENTAL DISORDERS  IPF","code_information":[{"code":"114","type":"RC"},{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1063.94,"maximum":1085.22,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1085.22,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1063.94,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Aspiration and/or injection of ganglion cyst(s) any location ","code_information":[{"code":"20612","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC ","code_information":[{"code":"066","type":"MS-DRG"},{"code":"200","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen) ","code_information":[{"code":"302","type":"RC"},{"code":"82820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.94,"maximum":52.03,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.03,"methodology":"fee schedule"}]}]},{"description":"Antibody; Blastomyces ","code_information":[{"code":"306","type":"RC"},{"code":"86612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.22,"maximum":50.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.31,"methodology":"fee schedule"}]}]},{"description":"TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) ","code_information":[{"code":"306","type":"RC"},{"code":"81352","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":542.04,"maximum":1285.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":542.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1266.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":602.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1285.09,"methodology":"fee schedule"}]}]},{"description":"BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC ","code_information":[{"code":"479","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sodium; other source ","code_information":[{"code":"309","type":"RC"},{"code":"84302","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.99,"maximum":18.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":18.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":18.95,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy, with biopsy(ies) with adjuctive blue light cystoscopy with fluorescent imaging agent ","code_information":[{"code":"369","type":"RC"},{"code":"C7550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC ","code_information":[{"code":"169","type":"RC"},{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated ","code_information":[{"code":"36478","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Interpelviabdominal amputation (hindquarter amputation) ","code_information":[{"code":"27290","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Red cell antigen (Kell blood group) genotyping (KEL), gene analysis, KEL (Kell metallo-endopeptidase) exon 8 ","code_information":[{"code":"0194U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"methodology":"fee schedule"}]}]},{"description":"Antibody; West Nile virus, IgM ","code_information":[{"code":"301","type":"RC"},{"code":"86788","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.72,"maximum":65.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.72,"methodology":"fee schedule"}]}]},{"description":"Repair of component(s) of a multi-component, inflatable penile prosthesis ","code_information":[{"code":"361","type":"RC"},{"code":"54408","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Glutathione ","code_information":[{"code":"306","type":"RC"},{"code":"82978","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.42,"maximum":60.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":59.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":60.25,"methodology":"fee schedule"}]}]},{"description":"FEVER AND INFLAMMATORY CONDITIONS ","code_information":[{"code":"138","type":"RC"},{"code":"864","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"49616","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy ","code_information":[{"code":"33243","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Antibody; encephalitis, California (La Crosse) ","code_information":[{"code":"302","type":"RC"},{"code":"86651","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.70,"maximum":51.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.44,"methodology":"fee schedule"}]}]},{"description":"Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG ºany form»), utilizing maternal serum, algorithm reported as a risk score ","code_information":[{"code":"306","type":"RC"},{"code":"81510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":91.36,"maximum":216.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":91.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":213.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":101.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":101.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":216.61,"methodology":"fee schedule"}]}]},{"description":"Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer ","code_information":[{"code":"27091","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"CHEST PAIN ","code_information":[{"code":"115","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy of testis, needle (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"54500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC ","code_information":[{"code":"117","type":"RC"},{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Parenteral nutrition supply kit; premix, per day ","code_information":[{"code":"B4220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":11.26,"maximum":11.38,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":11.26,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":11.38,"methodology":"fee schedule"}]}]},{"description":"Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s) ","code_information":[{"code":"499","type":"RC"},{"code":"61891","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) ","code_information":[{"code":"21180","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing ","code_information":[{"code":"304","type":"RC"},{"code":"81413","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":962.16,"maximum":2281.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":962.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2248.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2281.11,"methodology":"fee schedule"}]}]},{"description":"X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, ","code_information":[{"code":"81471","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":731.20,"maximum":3892.54,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":932.28,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1597.58,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":3892.54,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":3891.35,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":932.28,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":932.28,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":2667.87,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":3031.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":2425.39,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":3031.65,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":2323.84,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":914.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":731.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":950.56,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":918.57,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":914.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":914.00,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":950.56,"methodology":"fee schedule"}]}]},{"description":"Interpelviabdominal amputation (hindquarter amputation) ","code_information":[{"code":"27290","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":26605.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"ALLERGIC REACTIONS WITHOUT MCC ","code_information":[{"code":"202","type":"RC"},{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Rhytidectomy; forehead ","code_information":[{"code":"15824","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Scleral reinforcement (separate procedure); without graft ","code_information":[{"code":"67250","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype ","code_information":[{"code":"304","type":"RC"},{"code":"87501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.40,"maximum":200.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":197.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.11,"methodology":"fee schedule"}]}]},{"description":"Haloperidol ","code_information":[{"code":"300","type":"RC"},{"code":"80173","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.96,"maximum":61.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":60.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.54,"methodology":"fee schedule"}]}]},{"description":"Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; both components (battery and transmitter) ","code_information":[{"code":"0861T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19»), amplified probe technique ","code_information":[{"code":"87635","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":84.40,"maximum":200.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":197.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.11,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC ","code_information":[{"code":"059","type":"MS-DRG"},{"code":"148","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic ","code_information":[{"code":"45990","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Tyrosine ","code_information":[{"code":"84510","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":17.49,"maximum":41.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":40.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":41.46,"methodology":"fee schedule"}]}]},{"description":"Coronoidectomy (separate procedure) ","code_information":[{"code":"21070","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Hepatitis Be antibody (HBeAb) ","code_information":[{"code":"306","type":"RC"},{"code":"86707","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.03,"maximum":45.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45.12,"methodology":"fee schedule"}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple ","code_information":[{"code":"360","type":"RC"},{"code":"44377","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS ","code_information":[{"code":"157","type":"RC"},{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis) ","code_information":[{"code":"310","type":"RC"},{"code":"84738","type":"CDM"},{"code":"88363","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":40.58,"maximum":96.21,"gross_charge":1587.75,"discounted_cash":1587.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":40.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":94.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":45.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":96.21,"methodology":"fee schedule"}]}]},{"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":"323","type":"RC"},{"code":"76017","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":998.80,"maximum":1109.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":998.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1101.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1109.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1109.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1101.79,"methodology":"fee schedule"}]}]},{"description":"OSTEOMYELITIS WITH CC ","code_information":[{"code":"130","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Angiotensin I - converting enzyme (ACE) ","code_information":[{"code":"304","type":"RC"},{"code":"82164","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.02,"maximum":56.94,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":56.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.94,"methodology":"fee schedule"}]}]},{"description":"Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) ","code_information":[{"code":"0267T","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Inj, donanemab-azbt, 2 mg ","code_information":[{"code":"00765","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":4.01,"maximum":4.05,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":4.01,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":4.05,"methodology":"fee schedule"}]}]},{"description":"Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; ","code_information":[{"code":"28104","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC ","code_information":[{"code":"053","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant ºtypically using nonsequencing target variant analysis», or detection of a dynamic mutation disorder/t ","code_information":[{"code":"306","type":"RC"},{"code":"81401","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":225.37,"maximum":534.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":526.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":534.30,"methodology":"fee schedule"}]}]},{"description":"Application of finger splint; static ","code_information":[{"code":"29130","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Injection(s), bone-substitute material for bone and/or soft tissue hardware fixation augmentation, including intraoperative imaging guidance, when performed ","code_information":[{"code":"0869T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"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":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1908.20,"maximum":4524.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1908.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4459.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2120.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2120.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4524.00,"methodology":"fee schedule"}]}]},{"description":"PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC ","code_information":[{"code":"067","type":"MS-DRG"},{"code":"153","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bundle of His recording ","code_information":[{"code":"499","type":"RC"},{"code":"93600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29614.00,"maximum":51885.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC ","code_information":[{"code":"098","type":"MS-DRG"},{"code":"111","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphaden ","code_information":[{"code":"369","type":"RC"},{"code":"58951","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Bilirubin; direct ","code_information":[{"code":"301","type":"RC"},{"code":"36871","type":"CDM"},{"code":"82248","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.26,"maximum":19.58,"gross_charge":164.50,"discounted_cash":164.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.58,"methodology":"fee schedule"}]}]},{"description":"Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with closure of ventricular septal defect ","code_information":[{"code":"33776","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC ","code_information":[{"code":"696","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3020.07,"maximum":3051.20,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3020.07,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3051.20,"methodology":"fee schedule"}]}]},{"description":"Vestibuloplasty; posterior, unilateral ","code_information":[{"code":"40842","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Vaginoplasty for intersex state ","code_information":[{"code":"361","type":"RC"},{"code":"57335","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"146","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC ","code_information":[{"code":"207","type":"RC"},{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC  IPF","code_information":[{"code":"124","type":"RC"},{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":935.36,"maximum":954.07,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":954.07,"methodology":"fee schedule","additional_payer_notes":"Days 9. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":935.36,"methodology":"fee schedule","additional_payer_notes":"Days 9. "}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"FRACTURES OF FEMUR WITH MCC ","code_information":[{"code":"167","type":"RC"},{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC ","code_information":[{"code":"206","type":"RC"},{"code":"922","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC ","code_information":[{"code":"151","type":"RC"},{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination; sternum, minimum of 2 views ","code_information":[{"code":"323","type":"RC"},{"code":"71120","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":47.13,"maximum":52.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":47.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":52.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":52.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.99,"methodology":"fee schedule"}]}]},{"description":"Aspiration of bladder; by needle ","code_information":[{"code":"51100","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Angiography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"329","type":"RC"},{"code":"75716","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":829.24,"maximum":921.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":829.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":914.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":921.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":921.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":914.74,"methodology":"fee schedule"}]}]},{"description":"Hepatitis B core antibody (HBcAb); IgM antibody ","code_information":[{"code":"301","type":"RC"},{"code":"86705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.36,"maximum":45.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":45.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45.90,"methodology":"fee schedule"}]}]},{"description":"Onc Brst CA Image Alys w/ AI Assmt 12 Features ","code_information":[{"code":"0220U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1161.78,"maximum":2754.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1161.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2714.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1291.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1291.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2754.38,"methodology":"fee schedule"}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC ","code_information":[{"code":"125","type":"RC"},{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm ","code_information":[{"code":"27048","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Osmotic fragility, RBC; unincubated ","code_information":[{"code":"309","type":"RC"},{"code":"85555","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.29,"maximum":29.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":29.13,"methodology":"fee schedule"}]}]},{"description":"Removal and replacement of total replacement heart system (artificial heart) ","code_information":[{"code":"33928","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision of neuroma; hand or foot, except digital nerve ","code_information":[{"code":"481","type":"RC"},{"code":"64782","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC ","code_information":[{"code":"499","type":"RC"},{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence ","code_information":[{"code":"81252","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":80.90,"maximum":430.66,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":90.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":103.14,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":176.75,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":430.66,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":430.53,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":103.14,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":103.14,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":295.16,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":335.40,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":268.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":335.40,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":257.10,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":101.12,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":80.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":105.16,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":101.63,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":101.12,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":101.12,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":92.72,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":105.16,"methodology":"fee schedule"}]}]},{"description":"Bradykinin ","code_information":[{"code":"82286","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8.49,"maximum":20.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20.12,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 ","code_information":[{"code":"22551","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":12033.90,"maximum":35000.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26550.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":35000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC ","code_information":[{"code":"113","type":"RC"},{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Wedge excision of skin of nail fold (eg, for ingrown toenail) ","code_information":[{"code":"11765","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"PNEUMOTHORAX WITHOUT CC/MCC ","code_information":[{"code":"155","type":"RC"},{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Glucose-6-phosphate dehydrogenase (G6PD); quantitative ","code_information":[{"code":"309","type":"RC"},{"code":"82955","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.96,"maximum":37.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37.83,"methodology":"fee schedule"}]}]},{"description":"Biovance, per square centimeter ","drug_information":{"unit":"1","type":"EA"},"code_information":[{"code":"493422","type":"CDM"},{"code":"Q4154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":129.65,"maximum":387.17,"gross_charge":12174.00,"discounted_cash":12174.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":387.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":387.17,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":175.59,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":199.51,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":159.60,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":199.51,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":129.65,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":130.99,"methodology":"fee schedule"}]}]},{"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":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC ","code_information":[{"code":"831","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3617.09,"maximum":3654.38,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":3617.09,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":3654.38,"methodology":"fee schedule"}]}]},{"description":"In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure ","code_information":[{"code":"301","type":"RC"},{"code":"88366","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":479.12,"maximum":1135.91,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":479.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1119.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":532.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":532.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1135.91,"methodology":"fee schedule"}]}]},{"description":"Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardial sac for drainage ","code_information":[{"code":"32659","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm ","code_information":[{"code":"17274","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa ","code_information":[{"code":"31295","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC ","code_information":[{"code":"158","type":"RC"},{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype ","code_information":[{"code":"307","type":"RC"},{"code":"87501","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":84.40,"maximum":200.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":84.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":197.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":93.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.11,"methodology":"fee schedule"}]}]},{"description":"Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) ","code_information":[{"code":"37780","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC  IPF","code_information":[{"code":"154","type":"RC"},{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1392.08,"maximum":1419.92,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1419.92,"methodology":"fee schedule","additional_payer_notes":"Days 2. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1392.08,"methodology":"fee schedule","additional_payer_notes":"Days 2. "}]}]},{"description":"Laryngoscopy, flexible; with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral ","code_information":[{"code":"31573","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"OSTEOMYELITIS WITHOUT CC/MCC ","code_information":[{"code":"111","type":"RC"},{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy ","code_information":[{"code":"369","type":"RC"},{"code":"67400","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"212","type":"RC"},{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Colposcopy of the vulva; ","code_information":[{"code":"490","type":"RC"},{"code":"56820","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease ºCOVID-19»); screen ","code_information":[{"code":"86408","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":69.45,"maximum":164.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":69.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":162.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":77.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":77.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":164.66,"methodology":"fee schedule"}]}]},{"description":"Heart-lung transplant with recipient cardiectomy-pneumonectomy ","code_information":[{"code":"33935","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"34846","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Episiotomy or vaginal repair, by other than attending ","code_information":[{"code":"59300","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Open treatment of orbital floor blowout fracture; combined approach ","code_information":[{"code":"21387","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic ","code_information":[{"code":"39541","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Phosphatase, alkaline; ","code_information":[{"code":"301","type":"RC"},{"code":"36833","type":"CDM"},{"code":"84075","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.52,"maximum":20.20,"gross_charge":489.25,"discounted_cash":489.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":20.20,"methodology":"fee schedule"}]}]},{"description":"Transfer, finger to another position without microvascular anastomosis ","code_information":[{"code":"26555","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy ","code_information":[{"code":"57155","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Arthrotomy, hip, with drainage (eg, infection) ","code_information":[{"code":"27030","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"PLEURAL EFFUSION WITH MCC ","code_information":[{"code":"119","type":"RC"},{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Ligation, major artery (eg, post-traumatic, rupture); abdomen ","code_information":[{"code":"37617","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, when performed) ","code_information":[{"code":"22610","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":67375.00,"maximum":67375.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":67375.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":67375.00,"methodology":"case rate"}]}]},{"description":"C-peptide ","code_information":[{"code":"302","type":"RC"},{"code":"84681","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.23,"maximum":81.16,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":79.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":81.16,"methodology":"fee schedule"}]}]},{"description":"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC ","code_information":[{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":34690.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":82595.420,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":73569.270,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":82595.420,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":82595.420,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10857.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25394.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28216.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28216.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":57618.960,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":12433.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28216.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28216.00,"methodology":"case rate"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":18595.16,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":12433.96,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":89025.000,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":98916.670,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":10646.32,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":27202.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":30923.820,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":24729.170,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":30923.820,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":55652.990,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":12190.16,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9752.13,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":35436.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":65519.930,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":35436.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12677.77,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":117463.550,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":52673.130,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":33013.440,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11751.31,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":75794.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":12190.16,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":12190.16,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11331.48,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12555.86,"methodology":"fee schedule"}]}]},{"description":"Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day ","code_information":[{"code":"361","type":"RC"},{"code":"64653","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile) ","code_information":[{"code":"499","type":"RC"},{"code":"51729","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) ","code_information":[{"code":"360","type":"RC"},{"code":"68328","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC ","code_information":[{"code":"207","type":"RC"},{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC ","code_information":[{"code":"379","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":4501.08,"maximum":4547.48,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":4501.08,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":4547.48,"methodology":"fee schedule"}]}]},{"description":"Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a bi ","code_information":[{"code":"306","type":"RC"},{"code":"81558","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5329.80,"maximum":12636.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5329.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":12454.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5922.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":12636.00,"methodology":"fee schedule"}]}]},{"description":"DEPRESSIVE NEUROSES  IPF","code_information":[{"code":"154","type":"RC"},{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1064.33,"maximum":1085.62,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1085.62,"methodology":"fee schedule","additional_payer_notes":"Days 7. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1064.33,"methodology":"fee schedule","additional_payer_notes":"Days 7. "}]}]},{"description":"Removal of transvenous pacemaker electrode(s); dual lead system ","code_information":[{"code":"33235","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) ","code_information":[{"code":"322","type":"RC"},{"code":"73219","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":384.42,"maximum":427.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":384.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":424.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":427.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":427.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":424.06,"methodology":"fee schedule"}]}]},{"description":"MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND CO ","code_information":[{"code":"124","type":"RC"},{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MINOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"169","type":"RC"},{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views ","code_information":[{"code":"409","type":"RC"},{"code":"72114","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":74.02,"maximum":82.22,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":74.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":81.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":82.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":82.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":81.65,"methodology":"fee schedule"}]}]},{"description":"Nfct Agent HIV Trgt Viral Next-Gnrj Seq Alys Alg ","code_information":[{"code":"0219U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1192.63,"maximum":2827.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1192.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2786.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1325.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1325.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2827.50,"methodology":"fee schedule"}]}]},{"description":"Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories ","code_information":[{"code":"E1811","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":149.90,"maximum":327.52,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":191.13,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":327.52,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":191.13,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":191.13,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":187.38,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":181.76,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":149.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":194.88,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":183.63,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":188.32,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":187.38,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":187.38,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":194.88,"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision; ischial bursa ","code_information":[{"code":"27060","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single ","code_information":[{"code":"26785","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts) ","code_information":[{"code":"324","type":"RC"},{"code":"77334","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":654.78,"maximum":727.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":654.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":722.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":727.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":727.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.30,"methodology":"fee schedule"}]}]},{"description":"Progenamatrix, per square centimeter ","code_information":[{"code":"Q4222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":129.31,"maximum":313.69,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":313.69,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":313.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":142.26,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":161.64,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":129.31,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":161.64,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":131.85,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":133.21,"methodology":"fee schedule"}]}]},{"description":"HIV WITH OR WITHOUT OTHER RELATED CONDITION ","code_information":[{"code":"156","type":"RC"},{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Injection, incobotulinumtoxin a, 1 unit ","code_information":[{"code":"J0588","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5.17,"maximum":14.24,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":6.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9.33,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":14.24,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":14.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":6.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":7.34,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":5.87,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":7.34,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5.17,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5.22,"methodology":"fee schedule"}]}]},{"description":"Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion ","code_information":[{"code":"69745","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Methemalbumin ","code_information":[{"code":"302","type":"RC"},{"code":"83857","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":17.67,"maximum":41.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":17.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":41.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":19.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":41.89,"methodology":"fee schedule"}]}]},{"description":"Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) ","code_information":[{"code":"490","type":"RC"},{"code":"64555","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":63632.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":36318.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":40353.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63632.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"\"Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk scorefor early acute rejection\" ","code_information":[{"code":"0319U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4359.25,"maximum":10335.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4359.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10186.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4844.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4844.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":10335.00,"methodology":"fee schedule"}]}]},{"description":"Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method ","code_information":[{"code":"28292","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75746","type":"CPT"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":436.95,"maximum":485.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":436.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":482.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":485.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":485.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":482.01,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each ","code_information":[{"code":"26740","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"MAJOR SKIN DISORDERS WITHOUT MCC ","code_information":[{"code":"120","type":"RC"},{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; with cyclectomy ","code_information":[{"code":"66605","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Inj pemetrexed (accord) 10 ","code_information":[{"code":"09127","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":9.44,"maximum":9.54,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":9.44,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":9.54,"methodology":"fee schedule"}]}]},{"description":"Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less ","code_information":[{"code":"11042","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"RESPIRATORY SIGNS AND SYMPTOMS ","code_information":[{"code":"158","type":"RC"},{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC ","code_information":[{"code":"140","type":"RC"},{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Anoscopy; with biopsy, single or multiple ","code_information":[{"code":"369","type":"RC"},{"code":"46606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps ","code_information":[{"code":"44392","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"120","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq ","code_information":[{"code":"490","type":"RC"},{"code":"C5275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Colectomy, total, abdominal, with proctectomy; with continent ileostomy ","code_information":[{"code":"360","type":"RC"},{"code":"44156","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Lymphangiography, extremity only, bilateral, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75803","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":278.23,"maximum":309.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":278.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":306.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":309.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":309.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":306.92,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, mastoids; less than 3 views per side ","code_information":[{"code":"322","type":"RC"},{"code":"70120","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":43.79,"maximum":48.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":43.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":48.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":48.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":48.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":48.31,"methodology":"fee schedule"}]}]},{"description":"MAJOR CHEST TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"120","type":"RC"},{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy ","code_information":[{"code":"499","type":"RC"},{"code":"66160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Culture, bacterial, urine; quantitative, sensitivity study ","code_information":[{"code":"303","type":"RC"},{"code":"P7001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":30.99,"maximum":73.48,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":72.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":73.48,"methodology":"fee schedule"}]}]},{"description":"In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure ","code_information":[{"code":"319","type":"RC"},{"code":"88365","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Biopsy, soft tissue of thigh or knee area; superficial ","code_information":[{"code":"27323","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views ","code_information":[{"code":"322","type":"RC"},{"code":"72082","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":365.97,"maximum":406.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":365.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":403.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":406.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":406.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":403.70,"methodology":"fee schedule"}]}]},{"description":"SKIN DEBRIDEMENT WITH MCC ","code_information":[{"code":"499","type":"RC"},{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ","code_information":[{"code":"322","type":"RC"},{"code":"75573","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1607.95,"maximum":1786.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1607.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1773.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1786.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1786.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1773.75,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC ","code_information":[{"code":"361","type":"RC"},{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Percutaneous transcatheter placement of iliac arteriovenous anastomosis implant, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessa ","code_information":[{"code":"0553T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"DIABETES WITH CC ","code_information":[{"code":"145","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Application, cast; figure-of-eight ","code_information":[{"code":"29049","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hemorrhoidectomy, internal and external, single column/group; ","code_information":[{"code":"46255","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC ","code_information":[{"code":"120","type":"RC"},{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DIGESTIVE MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"200","type":"RC"},{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence ","code_information":[{"code":"301","type":"RC"},{"code":"81364","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":533.93,"maximum":1265.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":533.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1247.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":593.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":593.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1265.86,"methodology":"fee schedule"}]}]},{"description":"Vestibuloplasty; anterior ","code_information":[{"code":"40840","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"156","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1002.29,"maximum":1002.29,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1002.29,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach ","code_information":[{"code":"490","type":"RC"},{"code":"58805","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length ","code_information":[{"code":"361","type":"RC"},{"code":"64895","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Division of sternocleidomastoid for torticollis, open operation; without cast application ","code_information":[{"code":"21720","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score ","code_information":[{"code":"0291U","type":"CPT"},{"code":"307","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2886.97,"maximum":6844.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2886.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":6746.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3208.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":6844.50,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY SIGNS AND SYMPTOMS ","code_information":[{"code":"113","type":"RC"},{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Reduction forehead; contouring only ","code_information":[{"code":"21137","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"ATHEROSCLEROSIS WITHOUT MCC ","code_information":[{"code":"136","type":"RC"},{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) ","code_information":[{"code":"409","type":"RC"},{"code":"G0279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":225.49,"maximum":250.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":225.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":248.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":250.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":250.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":248.74,"methodology":"fee schedule"}]}]},{"description":"Footrest, complete assembly, replacement only, each ","code_information":[{"code":"K0045","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":53.48,"maximum":116.85,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":68.19,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":116.85,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":68.19,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":68.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":66.85,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":64.84,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":53.48,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":69.52,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":65.51,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":67.18,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":66.85,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":66.85,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":69.52,"methodology":"fee schedule"}]}]},{"description":"Splenectomy; partial (separate procedure) ","code_information":[{"code":"38101","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"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":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; ","code_information":[{"code":"31570","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC ","code_information":[{"code":"147","type":"RC"},{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed ","code_information":[{"code":"27829","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"New Technology - Level 22 ","code_information":[{"code":"01522","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":2377.49,"maximum":2402.00,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2377.49,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2402.00,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, ribs, unilateral; 2 views ","code_information":[{"code":"409","type":"RC"},{"code":"71100","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":190.18,"maximum":211.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":190.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":209.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":211.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":211.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":209.79,"methodology":"fee schedule"}]}]},{"description":"Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; thoracic approach ","code_information":[{"code":"50526","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Prostate specific antigen (PSA); free ","code_information":[{"code":"38200","type":"CDM"},{"code":"84154","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.71,"maximum":78.30,"gross_charge":748.25,"discounted_cash":748.25,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":16.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":18.76,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":32.14,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":78.30,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":78.28,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":18.76,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":18.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":59.66,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":67.80,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":54.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":67.80,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":51.97,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":18.45,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":14.71,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":19.13,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18.48,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":18.39,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":16.86,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":19.13,"methodology":"fee schedule"}]}]},{"description":"Excision of cervical stump, vaginal approach; ","code_information":[{"code":"499","type":"RC"},{"code":"57550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Cerclage of cervix, during pregnancy; abdominal ","code_information":[{"code":"481","type":"RC"},{"code":"59325","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"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":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Blood glucose monitor with integrated voice synthesizer ","code_information":[{"code":"E2100","type":"HCPCS"}],"standard_charges":[{"modifiers":"NU","modifiers_description":"New equipment","setting":"outpatient","minimum":718.91,"maximum":1570.73,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":916.61,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1570.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":916.61,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":916.61,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":898.64,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":871.68,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":718.91,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":934.59,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":880.67,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":903.13,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":898.64,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":898.64,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":934.59,"methodology":"fee schedule"}]}]},{"description":"Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, HbA1c, insulin, hs-CRP, adiponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm repor ","code_information":[{"code":"303","type":"RC"},{"code":"81506","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":113.37,"maximum":268.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":113.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":264.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":125.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":125.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":268.79,"methodology":"fee schedule"}]}]},{"description":"Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) ","code_information":[{"code":"31090","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Removal of lens material; extracapsular (other than 66840, 66850, 66852) ","code_information":[{"code":"360","type":"RC"},{"code":"66940","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may incl ","code_information":[{"code":"99172","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.39,"maximum":71.12,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":70.39,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":71.12,"methodology":"fee schedule"}]}]},{"description":"Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft ","code_information":[{"code":"481","type":"RC"},{"code":"66180","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement) ","code_information":[{"code":"26542","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":" Nursery Newborn - Level IV  ","code_information":[{"code":"174","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":2903.76,"maximum":4589.00,"payers_information":[{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2903.76,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4039.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4589.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3671.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4589.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":46.90,"standard_charge_algorithm":"Reimbursement will be 46.9% of billable gross charges.","estimated_amount":415649.680,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"207","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Bone marrow imaging; whole body ","code_information":[{"code":"340","type":"RC"},{"code":"78104","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":181.96,"maximum":202.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":181.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":200.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":202.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":202.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":200.72,"methodology":"fee schedule"}]}]},{"description":"Perineoplasty, repair of perineum, nonobstetrical (separate procedure) ","code_information":[{"code":"481","type":"RC"},{"code":"56810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Excision or destruction of lesion of pharynx, any method ","code_information":[{"code":"42808","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Injection, cefazolin sodium (wg critical care), not therapeutically equivalent to j0690, 500 mg ","code_information":[{"code":"J0687","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.94,"maximum":2.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":1.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1.93,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2.98,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2.98,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1.35,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1.53,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1.23,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1.53,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.94,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.95,"methodology":"fee schedule"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with dilation, initial ","code_information":[{"code":"31528","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Obliteration of aortopulmonary septal defect; without cardiopulmonary bypass ","code_information":[{"code":"33813","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, ","code_information":[{"code":"0130U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":962.16,"maximum":2281.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":962.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2248.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2281.11,"methodology":"fee schedule"}]}]},{"description":"Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, utilizing vaginal-fluid specimens, ","code_information":[{"code":"303","type":"RC"},{"code":"81513","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":234.63,"maximum":556.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":234.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":548.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":260.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":260.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":556.26,"methodology":"fee schedule"}]}]},{"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":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":452.10,"maximum":1071.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":452.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1056.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":502.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1071.84,"methodology":"fee schedule"}]}]},{"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 ","code_information":[{"code":"304","type":"RC"},{"code":"81435","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":962.16,"maximum":2281.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":962.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2248.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1069.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2281.11,"methodology":"fee schedule"}]}]},{"description":"Urobilinogen, urine; quantitative, timed specimen ","code_information":[{"code":"303","type":"RC"},{"code":"84580","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.71,"maximum":37.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.46,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37.25,"methodology":"fee schedule"}]}]},{"description":"Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique ","code_information":[{"code":"45338","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC ","code_information":[{"code":"148","type":"RC"},{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY  IPF","code_information":[{"code":"156","type":"RC"},{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":966.50,"maximum":966.50,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":966.50,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter re ","code_information":[{"code":"47538","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of ","code_information":[{"code":"307","type":"RC"},{"code":"81442","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3526.22,"maximum":8360.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3526.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8240.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3918.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3918.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8360.04,"methodology":"fee schedule"}]}]},{"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"DYSEQUILIBRIUM ","code_information":[{"code":"149","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed ","code_information":[{"code":"39401","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Removal of tunneled intraperitoneal catheter ","code_information":[{"code":"49422","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC ","code_information":[{"code":"087","type":"MS-DRG"},{"code":"155","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration ","code_information":[{"code":"38227","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"409","type":"RC"},{"code":"73723","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2021.36,"maximum":2245.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2021.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2229.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2245.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2245.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2229.78,"methodology":"fee schedule"}]}]},{"description":"Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor ","code_information":[{"code":"38209","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"076","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Capsulotomy, wrist (eg, contracture) ","code_information":[{"code":"25085","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thymectomy, partial or total; transcervical approach (separate procedure) ","code_information":[{"code":"499","type":"RC"},{"code":"60520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) ","code_information":[{"code":"481","type":"RC"},{"code":"58542","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"072","type":"MS-DRG"},{"code":"157","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed ","code_information":[{"code":"301","type":"RC"},{"code":"87625","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":66.70,"maximum":158.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":66.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":155.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":74.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":74.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":158.14,"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":"302","type":"RC"},{"code":"87385","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.80,"maximum":51.67,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.67,"methodology":"fee schedule"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) ","code_information":[{"code":"329","type":"RC"},{"code":"74181","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":345.36,"maximum":383.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":345.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":380.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":383.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":383.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":380.97,"methodology":"fee schedule"}]}]},{"description":"Biopsy of epididymis, needle ","code_information":[{"code":"361","type":"RC"},{"code":"54800","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"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":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1908.20,"maximum":4524.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1908.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4459.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2120.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2120.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4524.00,"methodology":"fee schedule"}]}]},{"description":"Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) ","code_information":[{"code":"44376","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC ","code_information":[{"code":"126","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm ","code_information":[{"code":"11312","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm ","code_information":[{"code":"12004","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Endolymphatic sac operation; without shunt ","code_information":[{"code":"361","type":"RC"},{"code":"69805","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision ","code_information":[{"code":"310","type":"RC"},{"code":"88174","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":41.73,"maximum":98.94,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":41.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":97.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":46.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":46.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":98.94,"methodology":"fee schedule"}]}]},{"description":"Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) ","code_information":[{"code":"29830","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC ","code_information":[{"code":"154","type":"RC"},{"code":"391","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision of neuroma; cutaneous nerve, surgically identifiable ","code_information":[{"code":"361","type":"RC"},{"code":"64774","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"211","type":"RC"},{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; ","code_information":[{"code":"57260","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Decompression; plantar digital nerve ","code_information":[{"code":"64726","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC ","code_information":[{"code":"099","type":"MS-DRG"},{"code":"130","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DIABETES WITH CC ","code_information":[{"code":"148","type":"RC"},{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"77054","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":253.50,"maximum":281.62,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":253.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":279.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":281.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":281.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":279.64,"methodology":"fee schedule"}]}]},{"description":"Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; ","code_information":[{"code":"15956","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, ","code_information":[{"code":"0070U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1112.63,"maximum":2637.84,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1112.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2599.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1236.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1236.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2637.84,"methodology":"fee schedule"}]}]},{"description":"Viscosity ","code_information":[{"code":"37479","type":"CDM"},{"code":"85810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":9.34,"maximum":49.73,"gross_charge":365.25,"discounted_cash":365.25,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":10.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":11.90,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":20.40,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":49.73,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":49.71,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":11.90,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":11.90,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":37.86,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":43.02,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":34.42,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":43.02,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":11.67,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":11.71,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":9.34,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":12.14,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":11.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":11.73,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":11.67,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":11.67,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":10.70,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":12.14,"methodology":"fee schedule"}]}]},{"description":"Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock ","code_information":[{"code":"L5925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":322.63,"maximum":704.91,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":411.36,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":704.91,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":411.36,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":411.36,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":403.29,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":391.19,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":322.63,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":419.42,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":395.22,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":405.31,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":403.29,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":403.29,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":419.42,"methodology":"fee schedule"}]}]},{"description":"Intestinal allotransplantation; from cadaver donor ","code_information":[{"code":"44135","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Plastic operation on penis for epispadias distal to external sphincter; with incontinence ","code_information":[{"code":"499","type":"RC"},{"code":"54385","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified ","code_information":[{"code":"303","type":"RC"},{"code":"83520","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.41,"maximum":67.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67.35,"methodology":"fee schedule"}]}]},{"description":"Heinz bodies; direct ","code_information":[{"code":"85441","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6.91,"maximum":16.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.38,"methodology":"fee schedule"}]}]},{"description":"SKIN GRAFTS FOR INJURIES WITH CC/MCC ","code_information":[{"code":"904","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":43719.09,"maximum":44169.81,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":43719.09,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":44169.81,"methodology":"fee schedule"}]}]},{"description":"Cystectomy, partial; complicated (eg, postradiation, previous surgery, difficult location) ","code_information":[{"code":"51555","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closure of laceration, vestibule of mouth; 2.5 cm or less ","code_information":[{"code":"361","type":"RC"},{"code":"40830","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis ","code_information":[{"code":"304","type":"RC"},{"code":"87270","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":19.71,"maximum":46.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.72,"methodology":"fee schedule"}]}]},{"description":"Glucose; blood, reagent strip ","code_information":[{"code":"305","type":"RC"},{"code":"82948","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8.29,"maximum":19.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.66,"methodology":"fee schedule"}]}]},{"description":"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm ","code_information":[{"code":"12004","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal appr ","code_information":[{"code":"63056","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH M ","code_information":[{"code":"140","type":"RC"},{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, great toe; metatarsophalangeal joint ","code_information":[{"code":"28750","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SIGNS AND SYMPTOMS WITH MCC  IPF","code_information":[{"code":"136","type":"RC"},{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1247.30,"maximum":1247.30,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1247.30,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Chlamydia trachomatis ","code_information":[{"code":"306","type":"RC"},{"code":"87810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":58.05,"maximum":137.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":58.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":135.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":137.63,"methodology":"fee schedule"}]}]},{"description":"Ultrasonic guidance for placement of radiation therapy fields ","code_information":[{"code":"324","type":"RC"},{"code":"G6001","type":"HCPCS"}],"standard_charges":[{"modifiers":"TC","modifiers_description":"Technical component; Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles","setting":"outpatient","minimum":762.93,"maximum":847.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":762.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":841.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":847.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":847.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":841.60,"methodology":"fee schedule"}]}]},{"description":"Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) ","code_information":[{"code":"28286","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Injection, rituximab, 10 mg ","code_information":[{"code":"J9312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":74.14,"maximum":205.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":101.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":116.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":112.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":92.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":112.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":139.05,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":205.79,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":205.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":93.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":106.04,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":84.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":106.04,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":74.14,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":74.90,"methodology":"fee schedule"}]}]},{"description":"Oncology (ovarian), biochemical assays of 7 proteins (follicle stimulating hormone, human epididymis protein 4, apolipoprotein A-1, transferrin, beta-2 macroglobulin, prea0lbumin, and cancer antigen 1 ","code_information":[{"code":"0375U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1475.57,"maximum":3498.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1475.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":3448.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1639.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1639.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":3498.30,"methodology":"fee schedule"}]}]},{"description":"Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair ","code_information":[{"code":"E1010","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":108.38,"maximum":236.81,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":138.19,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":236.81,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":138.19,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":138.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":135.48,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":131.42,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":108.38,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":140.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":132.77,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":136.16,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":135.48,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":135.48,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":140.90,"methodology":"fee schedule"}]}]},{"description":"Tag, per square centimeter ","code_information":[{"code":"Q4261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":680.23,"maximum":1650.13,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1650.13,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1650.13,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":748.34,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":850.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":680.23,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":850.29,"methodology":"fee schedule"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) ","code_information":[{"code":"31622","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Proctoplasty; for stenosis ","code_information":[{"code":"45500","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Ammonia ","code_information":[{"code":"301","type":"RC"},{"code":"36847","type":"CDM"},{"code":"82140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.97,"maximum":56.82,"gross_charge":451.50,"discounted_cash":451.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":56.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":26.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":26.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":56.82,"methodology":"fee schedule"}]}]},{"description":"CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm ","code_information":[{"code":"12055","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Treatment devices, design and construction; simple (simple block, simple bolus) ","code_information":[{"code":"320","type":"RC"},{"code":"77332","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":88.92,"maximum":98.78,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":88.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":98.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":98.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":98.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":98.09,"methodology":"fee schedule"}]}]},{"description":"Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin) ","code_information":[{"code":"43510","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger) ","code_information":[{"code":"26433","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"200","type":"RC"},{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Red cell antigen (cromlton blood group) genotyping (CROM), gene analysis, CD55 (CD55 molecule) exons 1-10 ","code_information":[{"code":"0182U","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":241.08,"maximum":1283.41,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":307.38,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":526.73,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1283.41,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1283.02,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":307.38,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":307.38,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":879.61,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":999.55,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":799.66,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":999.55,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":766.18,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":301.35,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":241.08,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":313.40,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":302.86,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":301.35,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":301.35,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":313.40,"methodology":"fee schedule"}]}]},{"description":"Orbital implant (implant outside muscle cone); removal or revision ","code_information":[{"code":"499","type":"RC"},{"code":"67560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"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":[{"setting":"outpatient","minimum":1943.38,"maximum":2158.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1943.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2143.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2158.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2158.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2143.77,"methodology":"fee schedule"}]}]},{"description":"Miglustat, oral, 65 mg ","code_information":[{"code":"J1202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":37.21,"maximum":90.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":42.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":48.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":47.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":38.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":47.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.18,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":90.28,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":40.94,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":46.52,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":37.21,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":46.52,"methodology":"fee schedule"}]}]},{"description":"Hematology (inherited thrombocytopenia), geonomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid ","code_information":[{"code":"0276U","type":"CPT"},{"code":"301","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4027.88,"maximum":9549.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4027.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":9412.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4475.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4475.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9549.38,"methodology":"fee schedule"}]}]},{"description":"Psychiatry (anxiety disorders), mRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score ","code_information":[{"code":"0437U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.20,"maximum":2964.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2921.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2964.00,"methodology":"fee schedule"}]}]},{"description":"Sinusotomy, sphenoid, with or without biopsy; ","code_information":[{"code":"31050","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Progesterone ","code_information":[{"code":"84144","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":34.31,"maximum":81.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":80.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":81.35,"methodology":"fee schedule"}]}]},{"description":"Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography ","code_information":[{"code":"360","type":"RC"},{"code":"58345","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Valvuloplasty, mitral valve, with cardiopulmonary bypass; ","code_information":[{"code":"33425","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Venography, caval, superior, with serialography, radiological supervision and interpretation ","code_information":[{"code":"321","type":"RC"},{"code":"75827","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":263.22,"maximum":292.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":263.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":290.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":292.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":292.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":290.36,"methodology":"fee schedule"}]}]},{"description":"Enterolysis (freeing of intestinal adhesion) (separate procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"44005","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Construction of artificial vagina; with graft ","code_information":[{"code":"57292","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Graft for facial nerve paralysis; free muscle flap by microsurgical technique ","code_information":[{"code":"15842","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC ","code_information":[{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":34690.00,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":71346.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":63549.220,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":71346.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":71346.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":7403.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7462.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":27696.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":8291.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":49771.330,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":8177.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":8291.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22437.12,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":12229.83,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":8177.68,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":76899.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":85444.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":7259.72,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":23497.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":26712.040,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":21361.080,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":26712.040,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":48073.120,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8017.34,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":6413.87,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":30610.430,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":56596.190,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":30610.430,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":8338.03,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":101465.150,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":45499.110,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":28517.050,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":7728.71,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":65471.720,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":8017.34,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":8017.34,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":7726.93,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":8257.86,"methodology":"fee schedule"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH CC ","code_information":[{"code":"211","type":"RC"},{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; abdominal aorta ","code_information":[{"code":"0236T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia ","code_information":[{"code":"28545","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Bone graft with microvascular anastomosis; fibula ","code_information":[{"code":"20955","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair or internal or external fixation ","code_information":[{"code":"27848","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma ","code_information":[{"code":"369","type":"RC"},{"code":"61108","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Plastic operation on penis to correct angulation ","code_information":[{"code":"361","type":"RC"},{"code":"54360","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, splenectomy ","code_information":[{"code":"38120","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":25978.00,"maximum":31314.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Arteriovenous anastomosis, open; by upper arm basilic vein transposition ","code_information":[{"code":"361","type":"RC"},{"code":"36819","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) ","code_information":[{"code":"24363","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":11152.90,"maximum":50515.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31793.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50515.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Petrous apicectomy including radical mastoidectomy ","code_information":[{"code":"490","type":"RC"},{"code":"69530","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"All potassium hydroxide (koh) preparations ","code_information":[{"code":"300","type":"RC"},{"code":"Q0112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":9.59,"maximum":22.74,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":9.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":22.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":10.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":10.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":22.74,"methodology":"fee schedule"}]}]},{"description":"Tenodesis; of proximal interphalangeal joint, each joint ","code_information":[{"code":"26471","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Volume reduction of blood or blood product (eg, red blood cells or platelets), each unit ","code_information":[{"code":"301","type":"RC"},{"code":"86960","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Excision, trochanteric pressure ulcer, with primary suture; ","code_information":[{"code":"15950","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Oocyte identification from follicular fluid ","code_information":[{"code":"89254","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WIT ","code_information":[{"code":"369","type":"RC"},{"code":"497","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"114","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"128","type":"RC"},{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"UNCOMPLICATED PEPTIC ULCER WITH MCC ","code_information":[{"code":"131","type":"RC"},{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius ","code_information":[{"code":"25490","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Electrophoretic technique, not elsewhere specified ","code_information":[{"code":"309","type":"RC"},{"code":"82664","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":101.17,"maximum":239.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":101.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":236.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":112.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":112.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":239.85,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, glenohumeral joint; ","code_information":[{"code":"23800","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75743","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":383.60,"maximum":426.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":383.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":423.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":426.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":426.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":423.15,"methodology":"fee schedule"}]}]},{"description":"MINOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"111","type":"RC"},{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique ","code_information":[{"code":"361","type":"RC"},{"code":"46615","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Immunoassay for infectious agent antibody, quantitative, not otherwise specified ","code_information":[{"code":"302","type":"RC"},{"code":"86317","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.66,"maximum":58.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.46,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antibody detection by rapid antibody test, hiv-1 and/or hiv-2, screening ","code_information":[{"code":"925","type":"RC"},{"code":"G0435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":19.71,"maximum":46.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":46.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":46.72,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine; thoracic, 3 views ","code_information":[{"code":"324","type":"RC"},{"code":"72072","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":53.92,"maximum":59.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":53.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":59.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":59.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":59.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":59.48,"methodology":"fee schedule"}]}]},{"description":"Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated or stra ","code_information":[{"code":"360","type":"RC"},{"code":"49492","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CEBPA (CCAAT/enhancer binding protein ºC/EBP», alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence ","code_information":[{"code":"305","type":"RC"},{"code":"81218","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":397.93,"maximum":943.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":397.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":929.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":442.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":442.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":943.41,"methodology":"fee schedule"}]}]},{"description":"Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation ","code_information":[{"code":"499","type":"RC"},{"code":"67039","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) ","code_information":[{"code":"20555","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Trabeculostomy ab interno by laser; with use of ophthalmic endoscope ","code_information":[{"code":"0622T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CELLULITIS WITHOUT MCC ","code_information":[{"code":"147","type":"RC"},{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of left ","code_information":[{"code":"400","type":"RC"},{"code":"75573","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1607.95,"maximum":1786.26,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1607.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1773.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1786.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1786.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1773.75,"methodology":"fee schedule"}]}]},{"description":"Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) ","code_information":[{"code":"25820","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Curettage, postpartum ","code_information":[{"code":"369","type":"RC"},{"code":"59160","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated) ","code_information":[{"code":"306","type":"RC"},{"code":"99001","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.91,"maximum":25.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":25.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":25.86,"methodology":"fee schedule"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique ","code_information":[{"code":"304","type":"RC"},{"code":"87475","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.98,"maximum":78.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.20,"methodology":"fee schedule"}]}]},{"description":"Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon ","code_information":[{"code":"26412","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES ","code_information":[{"code":"018","type":"MS-DRG"},{"code":"136","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Treatment devices, design and construction; simple (simple block, simple bolus) ","code_information":[{"code":"324","type":"RC"},{"code":"77332","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":88.92,"maximum":98.78,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":88.92,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":98.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":98.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":98.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":98.09,"methodology":"fee schedule"}]}]},{"description":"Excision of thyroglossal duct cyst or sinus; ","code_information":[{"code":"60280","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19023.00,"maximum":22929.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"}]}]},{"description":"PLEURAL EFFUSION WITHOUT CC/MCC ","code_information":[{"code":"188","type":"MS-DRG"},{"code":"212","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT ","code_information":[{"code":"124","type":"MS-DRG"},{"code":"208","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated ","code_information":[{"code":"40801","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Neuroplasty; nerve of hand or foot ","code_information":[{"code":"64704","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"HYPERTENSION WITHOUT MCC ","code_information":[{"code":"140","type":"RC"},{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach ","code_information":[{"code":"499","type":"RC"},{"code":"61546","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"AFTERCARE WITHOUT CC/MCC ","code_information":[{"code":"100","type":"RC"},{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Computed tomography, abdomen; without contrast material ","code_information":[{"code":"329","type":"RC"},{"code":"74150","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":281.57,"maximum":312.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":281.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":310.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":312.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":312.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":310.60,"methodology":"fee schedule"}]}]},{"description":"Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery ","code_information":[{"code":"42970","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspirationºs»/biopsyºies ","code_information":[{"code":"31652","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous ","code_information":[{"code":"33946","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative o ","code_information":[{"code":"306","type":"RC"},{"code":"81316","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":341.02,"maximum":808.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":341.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":796.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":808.51,"methodology":"fee schedule"}]}]},{"description":"Pericardiotomy for removal of clot or foreign body (primary procedure) ","code_information":[{"code":"33020","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"MAJOR SKIN DISORDERS WITH MCC ","code_information":[{"code":"116","type":"RC"},{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Psychiatry (eg, depression, anxiety), geonomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition ","code_information":[{"code":"0423U","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"Repositioning of previously implanted subcutaneous implantable defibrillator electrode ","code_information":[{"code":"33273","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (eg, using flow cytometry); each additional serum sample or sample dilution (List separately in addition to primary procedure) ","code_information":[{"code":"303","type":"RC"},{"code":"86826","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":60.09,"maximum":142.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":60.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":140.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":66.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":66.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":142.47,"methodology":"fee schedule"}]}]},{"description":"Antibody; Blastomyces ","code_information":[{"code":"301","type":"RC"},{"code":"86612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.22,"maximum":50.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.31,"methodology":"fee schedule"}]}]},{"description":"Level 5 hospital emergency department visit provided in a type b emergency department; (the ed must meet at least one of the following requirements: (1) it is licensed by the state in which it is loca ","code_information":[{"code":"450","type":"RC"},{"code":"G0384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":5135.00,"maximum":10362.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":5135.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":10362.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5706.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5706.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":10362.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination from nose to rectum for foreign body, single view, child ","code_information":[{"code":"400","type":"RC"},{"code":"76010","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":108.15,"maximum":120.14,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":108.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":119.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":120.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":120.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":119.30,"methodology":"fee schedule"}]}]},{"description":"Hydroxyproline; free ","code_information":[{"code":"304","type":"RC"},{"code":"83500","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.26,"maximum":88.33,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":37.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":87.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":41.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":88.33,"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":6.11,"maximum":16.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":6.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":9.18,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":16.55,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":16.55,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":7.50,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":8.53,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":6.82,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":8.53,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":6.12,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":6.18,"methodology":"fee schedule"}]}]},{"description":"Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger ","code_information":[{"code":"26426","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Axicabtagene ciloleucel ca ","code_information":[{"code":"09035","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":517233.29,"maximum":522565.60,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":517233.29,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":522565.60,"methodology":"fee schedule"}]}]},{"description":"MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC ","code_information":[{"code":"134","type":"RC"},{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CONCUSSION WITH CC ","code_information":[{"code":"089","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearra ","code_information":[{"code":"0242U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8225.00,"maximum":19500.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8225.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19220.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9140.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9140.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19500.00,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine, cervical; 6 or more views ","code_information":[{"code":"409","type":"RC"},{"code":"72052","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":322.28,"maximum":358.02,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":322.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":355.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":358.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":358.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":355.51,"methodology":"fee schedule"}]}]},{"description":"Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon ","code_information":[{"code":"481","type":"RC"},{"code":"61623","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITHOUT MCC ","code_information":[{"code":"055","type":"MS-DRG"},{"code":"126","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"C-reactive protein; high sensitivity (hsCRP) ","code_information":[{"code":"303","type":"RC"},{"code":"86141","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.30,"maximum":50.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":49.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":50.50,"methodology":"fee schedule"}]}]},{"description":"Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty, transabdominal or transthoracic approach ","code_information":[{"code":"361","type":"RC"},{"code":"43320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, ","code_information":[{"code":"81434","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":478.33,"maximum":2546.37,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":609.87,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1045.09,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2546.37,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2545.59,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":609.87,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":609.87,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1745.24,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1983.21,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1586.61,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1983.21,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":1520.19,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":597.91,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":478.33,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":621.83,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":600.90,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":597.91,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":597.91,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":621.83,"methodology":"fee schedule"}]}]},{"description":"Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction ","code_information":[{"code":"69643","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75630","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":333.64,"maximum":370.64,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":333.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":368.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":370.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":370.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":368.04,"methodology":"fee schedule"}]}]},{"description":"Intracavitary radiation source application; simple ","code_information":[{"code":"409","type":"RC"},{"code":"77761","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2205.21,"maximum":2449.76,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2205.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2432.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2449.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2449.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2432.60,"methodology":"fee schedule"}]}]},{"description":"AFF2 (ALF transcription elongation factor 2 ºFMR2») (eg, fragile X intellectual disability 2 ºFRAXE») gene analysis; characterization of alleles (eg, expanded size and methylation status) ","code_information":[{"code":"81172","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":219.86,"maximum":1170.45,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":244.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":480.38,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1170.45,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1170.09,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":280.33,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":802.20,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":911.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":729.29,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":911.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":698.76,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":219.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":285.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":276.20,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":274.83,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":251.99,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":285.82,"methodology":"fee schedule"}]}]},{"description":"Androstenedione ","code_information":[{"code":"304","type":"RC"},{"code":"82157","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":48.17,"maximum":114.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":48.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":112.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":53.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":53.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":114.19,"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":"301","type":"RC"},{"code":"81508","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":89.32,"maximum":211.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":89.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":208.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":99.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":99.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":211.77,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, finger(s), minimum of 2 views ","code_information":[{"code":"73140","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":121.45,"maximum":405.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":405.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":405.00,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":133.59,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":151.81,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":121.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":151.81,"methodology":"fee schedule"}]}]},{"description":"Injection, lepirudin, 50 mg ","code_information":[{"code":"J1945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.01,"maximum":1530.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.02,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1530.19,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1530.19,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":693.95,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":788.49,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":630.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":788.49,"methodology":"fee schedule"}]}]},{"description":"Suture of tracheal wound or injury; cervical ","code_information":[{"code":"31800","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Tubing (oxygen), per foot ","code_information":[{"code":"A4616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":0.06,"maximum":0.14,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":0.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":0.06,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":0.08,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":0.08,"methodology":"fee schedule"}]}]},{"description":"Percutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance ","code_information":[{"code":"0632T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT ","code_information":[{"code":"151","type":"RC"},{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed ","code_information":[{"code":"309","type":"RC"},{"code":"87522","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":70.47,"maximum":167.08,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":70.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":164.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":78.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":78.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":167.08,"methodology":"fee schedule"}]}]},{"description":"Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) ","code_information":[{"code":"360","type":"RC"},{"code":"44401","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"BRONCHITIS AND ASTHMA WITH CC/MCC ","code_information":[{"code":"138","type":"RC"},{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage; photocoagulation ","code_information":[{"code":"490","type":"RC"},{"code":"67145","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"200","type":"RC"},{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff) ","code_information":[{"code":"24341","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial ","code_information":[{"code":"490","type":"RC"},{"code":"61320","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"URINARY STONES WITH MCC ","code_information":[{"code":"137","type":"RC"},{"code":"693","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and reco ","code_information":[{"code":"360","type":"RC"},{"code":"93620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":51885.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Receptor assay; estrogen ","code_information":[{"code":"309","type":"RC"},{"code":"84233","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":144.56,"maximum":342.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":144.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":337.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":160.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":160.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":342.73,"methodology":"fee schedule"}]}]},{"description":"Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation ","code_information":[{"code":"28300","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm ","code_information":[{"code":"17107","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC ","code_information":[{"code":"060","type":"MS-DRG"},{"code":"133","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique ","code_information":[{"code":"309","type":"RC"},{"code":"87528","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.98,"maximum":78.20,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":77.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":36.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":78.20,"methodology":"fee schedule"}]}]},{"description":"Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion ","code_information":[{"code":"340","type":"RC"},{"code":"79403","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":873.39,"maximum":970.24,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":873.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":963.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":970.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":970.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":963.45,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of femoral fracture, proximal end, head; with manipulation ","code_information":[{"code":"27268","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Red cell antigen (colton blood group) genotyping (CO), gene analysis, AQP1 (aquaporin 1) exon 1 ","code_information":[{"code":"0181U","type":"CPT"},{"code":"309","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":304.65,"maximum":722.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":304.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":711.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":338.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":722.28,"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections ","code_information":[{"code":"409","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":1033.91,"maximum":1148.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1033.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1140.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1148.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1148.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1140.52,"methodology":"fee schedule"}]}]},{"description":"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY ","code_information":[{"code":"490","type":"RC"},{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"305","type":"RC"},{"code":"G0483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":406.18,"maximum":962.99,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":406.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":949.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":451.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":451.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":962.99,"methodology":"fee schedule"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) ","code_information":[{"code":"43280","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"SPINAL DISORDERS AND INJURIES WITH CC/MCC ","code_information":[{"code":"052","type":"MS-DRG"},{"code":"203","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with graft ","code_information":[{"code":"33845","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Antibody; varicella-zoster ","code_information":[{"code":"86787","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10.30,"maximum":54.84,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":11.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":13.14,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":22.51,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":54.84,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":54.82,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":13.14,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":13.14,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":41.77,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":47.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":37.97,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":47.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":36.38,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":12.88,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":12.92,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":10.30,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":13.40,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":13.05,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":12.94,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":12.88,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":12.88,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":11.81,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":13.40,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cm ","code_information":[{"code":"26117","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Ehrlichia chaffeensis, amplified probe technique ","code_information":[{"code":"87484","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":57.72,"maximum":136.85,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":57.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":134.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":64.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":136.85,"methodology":"fee schedule"}]}]},{"description":"Antibody; Salmonella ","code_information":[{"code":"304","type":"RC"},{"code":"86768","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.70,"maximum":51.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":50.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51.44,"methodology":"fee schedule"}]}]},{"description":"OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"208","type":"RC"},{"code":"393","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Gastrojejunostomy; without vagotomy ","code_information":[{"code":"43820","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"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":"400","type":"RC"},{"code":"77085","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":280.23,"maximum":311.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":280.23,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":309.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":311.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":311.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":309.13,"methodology":"fee schedule"}]}]},{"description":"RENAL FAILURE WITHOUT CC/MCC ","code_information":[{"code":"147","type":"RC"},{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC ","code_information":[{"code":"154","type":"RC"},{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Photorefractive keratectomy (prk) ","code_information":[{"code":"481","type":"RC"},{"code":"S0810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":2258.56,"payers_information":[{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) ","code_information":[{"code":"29875","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Correction of trichiasis; incision of lid margin ","code_information":[{"code":"67830","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA/RNA), vaginal pathogen panel, identification of 27 organisms, amplified probe technique, vaginal swab ","code_information":[{"code":"0330U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS  IPF","code_information":[{"code":"116","type":"RC"},{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1385.31,"maximum":1385.31,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1385.31,"methodology":"fee schedule","additional_payer_notes":"Days 5. "}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed ","code_information":[{"code":"43210","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Reduction forehead; contouring only ","code_information":[{"code":"21137","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments ","code_information":[{"code":"22804","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":26605.10,"maximum":83200.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":67500.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":75000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":75000.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":83200.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan ","code_information":[{"code":"329","type":"RC"},{"code":"77338","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2456.82,"maximum":2729.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2456.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2710.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2729.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2729.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2710.15,"methodology":"fee schedule"}]}]},{"description":"Laryngectomy; subtotal supraglottic, with radical neck dissection ","code_information":[{"code":"31368","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES ","code_information":[{"code":"204","type":"RC"},{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external ","code_information":[{"code":"53010","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Repair of entropion; suture ","code_information":[{"code":"67921","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine ","code_information":[{"code":"0316U","type":"CPT"},{"code":"300","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30.70,"maximum":72.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":30.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":71.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":72.77,"methodology":"fee schedule"}]}]},{"description":"OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC ","code_information":[{"code":"114","type":"RC"},{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH CC ","code_information":[{"code":"160","type":"RC"},{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Open treatment of acute or chronic elbow dislocation ","code_information":[{"code":"24615","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial ","code_information":[{"code":"61512","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Chemical peel, nonfacial; dermal ","code_information":[{"code":"15793","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":343.70,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":343.70,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":343.70,"methodology":"case rate"}]}]},{"description":"PULMONARY EMBOLISM WITHOUT MCC ","code_information":[{"code":"176","type":"MS-DRG"},{"code":"210","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites ","code_information":[{"code":"87209","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":29.58,"maximum":70.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":69.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":70.12,"methodology":"fee schedule"}]}]},{"description":"Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less ","code_information":[{"code":"15155","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"OTITIS MEDIA AND URI WITH MCC ","code_information":[{"code":"133","type":"RC"},{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, ","code_information":[{"code":"58943","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"New Technology - Level 47 ","code_information":[{"code":"01584","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":89796.83,"maximum":90722.57,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":89796.83,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":90722.57,"methodology":"fee schedule"}]}]},{"description":"Injection of medication or other substance into Tenon's capsule ","code_information":[{"code":"67515","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC ","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":30123.18,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":58085.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":51737.410,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":58085.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":58085.020,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":8212.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8115.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":30123.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9017.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":40520.390,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":8894.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9017.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":24402.59,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":13301.16,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21811.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":26105.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":8894.04,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":62606.610,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":69562.900,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":8053.15,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":19129.800,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":21747.100,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":17390.730,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":21747.100,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":39137.830,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":1967.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":8719.65,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":6975.72,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":24920.910,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":46076.730,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":24920.910,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":9068.43,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":82605.950,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":4679.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":37042.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":23216.620,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":8405.74,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":53302.580,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":8719.65,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":8719.65,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":8571.43,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":8981.24,"methodology":"fee schedule"}]}]},{"description":"Surgery of intracranial arteriovenous malformation; infratentorial, simple ","code_information":[{"code":"61684","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC ","code_information":[{"code":"133","type":"RC"},{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, hip, arthrography, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"73525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":648.87,"maximum":720.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":648.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":715.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":720.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":720.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":715.78,"methodology":"fee schedule"}]}]},{"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":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4802.74,"maximum":11386.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4802.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":11222.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5337.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5337.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":11386.44,"methodology":"fee schedule"}]}]},{"description":"Injection, margetuximab-cmkb, 5 mg ","drug_information":{"unit":"250","type":"ME"},"code_information":[{"code":"116440","type":"CDM"},{"code":"J9353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":47.07,"maximum":132.49,"gross_charge":14342.25,"discounted_cash":14342.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":62.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":72.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":69.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":57.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":69.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":86.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":132.49,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":132.49,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":60.09,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":68.27,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":54.62,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":68.27,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":47.07,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":47.56,"methodology":"fee schedule"}]}]},{"description":"Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction ","code_information":[{"code":"369","type":"RC"},{"code":"69644","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Injection, phytonadione (vitamin k), per 1 mg ","code_information":[{"code":"J3430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.38,"maximum":5.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":4.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":3.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":4.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5.10,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5.93,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":5.93,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":2.69,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":3.05,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":2.44,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":3.05,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2.38,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2.40,"methodology":"fee schedule"}]}]},{"description":" Extra-Corporeal Shock Wave Therapy (formerly Lithotripsy) General Classification  Minor","code_information":[{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","payers_information":[{"payer_name":"MVP Health Plan","plan_name":"COMM","standard_charge_percentage":70.00,"standard_charge_algorithm":"Reimbursement will be 70% of billable gross charges.","estimated_amount":34743.630,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."}]}]},{"description":"Cyanocobalamin (Vitamin B-12); ","code_information":[{"code":"309","type":"RC"},{"code":"82607","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.81,"maximum":58.81,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.81,"methodology":"fee schedule"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH MCC ","code_information":[{"code":"196","type":"MS-DRG"},{"code":"211","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Drainage of perineal urinary extravasation; uncomplicated (separate procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"53080","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Unlisted laparoscopy procedure, maternity care and delivery ","code_information":[{"code":"59898","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Carbamazepine; -10,11-epoxide ","code_information":[{"code":"80161","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":14.91,"maximum":79.41,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":16.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":19.01,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":32.58,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":79.41,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":79.39,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":19.01,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":19.01,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":54.41,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":61.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":49.46,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":61.83,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":47.39,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":18.69,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":14.91,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":19.39,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":18.88,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":18.73,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":18.64,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":17.09,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":19.39,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study ","code_information":[{"code":"324","type":"RC"},{"code":"74220","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":498.22,"maximum":553.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":498.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":549.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":553.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":553.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":549.59,"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":"324","type":"RC"},{"code":"72197","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":523.51,"maximum":581.56,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":523.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":577.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":581.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":581.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":577.49,"methodology":"fee schedule"}]}]},{"description":"Gammaglobulin (immunoglobulin); IgE ","code_information":[{"code":"82785","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":27.08,"maximum":64.19,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":63.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":64.19,"methodology":"fee schedule"}]}]},{"description":"Thoracotomy; with open intrapleural pneumonolysis ","code_information":[{"code":"32124","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir ºS or J»); with biopsy, single or multiple ","code_information":[{"code":"44386","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2000.00,"maximum":2000.00,"payers_information":[{"payer_name":"MVP Health Plan","plan_name":"COMM","standard_charge_dollar":2000.00,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy with transurethral resection or incision of ejaculatory ducts ","code_information":[{"code":"361","type":"RC"},{"code":"52402","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; Rubeola ","code_information":[{"code":"304","type":"RC"},{"code":"87283","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":100.02,"maximum":237.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":100.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":233.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":111.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":111.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":237.12,"methodology":"fee schedule"}]}]},{"description":"Kidney imaging morphology; with vascular flow ","code_information":[{"code":"342","type":"RC"},{"code":"78701","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":116.37,"maximum":129.27,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":116.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":128.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":129.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":129.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":128.37,"methodology":"fee schedule"}]}]},{"description":"Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast ","code_information":[{"code":"27165","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Surgery of intracranial arteriovenous malformation; infratentorial, complex ","code_information":[{"code":"481","type":"RC"},{"code":"61686","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection ","code_information":[{"code":"305","type":"RC"},{"code":"87250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":32.18,"maximum":76.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":32.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":75.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":35.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":35.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":76.28,"methodology":"fee schedule"}]}]},{"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":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1878.69,"maximum":4454.03,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1878.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4390.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2087.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2087.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4454.03,"methodology":"fee schedule"}]}]},{"description":"Cerclage of cervix, during pregnancy; vaginal ","code_information":[{"code":"59320","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Computed tomography, abdomen; without contrast material ","code_information":[{"code":"324","type":"RC"},{"code":"74150","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":715.39,"maximum":794.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":715.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":789.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":794.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":794.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":789.15,"methodology":"fee schedule"}]}]},{"description":"MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC ","code_information":[{"code":"059","type":"MS-DRG"},{"code":"209","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC ","code_information":[{"code":"101","type":"RC"},{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Level 3 hospital emergency department visit provided in a type b emergency department; (the ed must meet at least one of the following requirements: (1) it is licensed by the state in which it is loca ","code_information":[{"code":"450","type":"RC"},{"code":"G0382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2201.00,"maximum":4598.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2201.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4598.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2446.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2446.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4598.00,"methodology":"case rate"}]}]},{"description":"Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) ","code_information":[{"code":"32507","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Biopsy of lip ","code_information":[{"code":"360","type":"RC"},{"code":"40490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Splenectomy; total (separate procedure) ","code_information":[{"code":"38100","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"125","type":"RC"},{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy ","code_information":[{"code":"21743","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) ","code_information":[{"code":"20979","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for pri ","code_information":[{"code":"0072U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":741.75,"maximum":1758.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":741.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1733.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":824.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":824.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1758.55,"methodology":"fee schedule"}]}]},{"description":"Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet ","code_information":[{"code":"15620","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"HIV WITH OR WITHOUT OTHER RELATED CONDITION ","code_information":[{"code":"131","type":"RC"},{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":"305","type":"RC"},{"code":"81107","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":201.05,"maximum":476.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":201.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":469.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":223.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":476.66,"methodology":"fee schedule"}]}]},{"description":"Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) ","code_information":[{"code":"322","type":"RC"},{"code":"77470","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":547.31,"maximum":608.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":547.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":603.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":608.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":608.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":603.74,"methodology":"fee schedule"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"138","type":"RC"},{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INTERSTITIAL LUNG DISEASE WITH MCC ","code_information":[{"code":"127","type":"RC"},{"code":"196","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Construction of artificial vagina; with graft ","code_information":[{"code":"369","type":"RC"},{"code":"57292","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Organic acid, single, quantitative ","code_information":[{"code":"300","type":"RC"},{"code":"83921","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":34.89,"maximum":82.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":34.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":81.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":38.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":38.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":82.72,"methodology":"fee schedule"}]}]},{"description":"Hemoglobin; glycosylated (A1C) ","code_information":[{"code":"83036","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":15.97,"maximum":37.87,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.33,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":37.87,"methodology":"fee schedule"}]}]},{"description":"BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC ","code_information":[{"code":"369","type":"RC"},{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC ","code_information":[{"code":"140","type":"RC"},{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"75630","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":795.72,"maximum":883.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":795.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":877.77,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":883.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":883.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":877.77,"methodology":"fee schedule"}]}]},{"description":"Angiography, spinal, selective, radiological supervision and interpretation ","code_information":[{"code":"324","type":"RC"},{"code":"75705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1312.96,"maximum":1458.56,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1312.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1448.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1458.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1458.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1448.34,"methodology":"fee schedule"}]}]},{"description":"Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type) ","code_information":[{"code":"31075","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC ","code_information":[{"code":"153","type":"RC"},{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Chromosome analysis; additional cells counted, each study ","code_information":[{"code":"319","type":"RC"},{"code":"88285","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.27,"maximum":104.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":103.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":49.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":49.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":104.95,"methodology":"fee schedule"}]}]},{"description":"Dialysis ","code_information":[{"code":"05401","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":739.20,"maximum":746.82,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":739.20,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":746.82,"methodology":"fee schedule"}]}]},{"description":"FLT3 (fms-related tyrosine kinase 3) (eg, acute lyeloid leukemia) internal tandem duplication (ITD) variants, quantitative ","code_information":[{"code":"0046U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":670.22,"maximum":1588.98,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":670.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1566.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":744.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":744.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1588.98,"methodology":"fee schedule"}]}]},{"description":"Cryofibrinogen ","code_information":[{"code":"305","type":"RC"},{"code":"82585","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":23.26,"maximum":55.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":23.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":54.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":25.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":25.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":55.15,"methodology":"fee schedule"}]}]},{"description":"Venography, venous sinus (eg, petrosal and inferior sagittal) or jugular, catheter, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"55218","type":"CDM"},{"code":"75860","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":382.67,"maximum":425.11,"gross_charge":15811.00,"discounted_cash":15811.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":382.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":422.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":425.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":425.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":422.13,"methodology":"fee schedule"}]}]},{"description":"CELLULITIS WITH MCC ","code_information":[{"code":"125","type":"RC"},{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"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":723.80,"maximum":1716.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":723.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1691.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":804.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":804.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1716.00,"methodology":"fee schedule"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"116","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) ","code_information":[{"code":"26852","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC ","code_information":[{"code":"142","type":"RC"},{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days ","code_information":[{"code":"349","type":"RC"},{"code":"78266","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":242.51,"maximum":269.40,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":242.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":267.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":269.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":269.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":267.51,"methodology":"fee schedule"}]}]},{"description":"ANGINA PECTORIS ","code_information":[{"code":"200","type":"RC"},{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; ","code_information":[{"code":"69660","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) ","code_information":[{"code":"45303","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Bone graft, any donor area; minor or small (eg, dowel or button) ","code_information":[{"code":"20900","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only ","code_information":[{"code":"42205","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"BRONCHITIS AND ASTHMA WITH CC/MCC ","code_information":[{"code":"149","type":"RC"},{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Iridectomy, with corneoscleral or corneal section; with cyclectomy ","code_information":[{"code":"490","type":"RC"},{"code":"66605","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Leukocyte alkaline phosphatase with count ","code_information":[{"code":"85540","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":14.15,"maximum":33.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":14.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":33.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":15.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":15.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":33.54,"methodology":"fee schedule"}]}]},{"description":"Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material ","code_information":[{"code":"321","type":"RC"},{"code":"74261","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":2164.45,"maximum":2404.48,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2164.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2387.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2404.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2404.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2387.64,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of calcaneal fracture; with manipulation ","code_information":[{"code":"28405","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"CONCUSSION WITHOUT CC/MCC ","code_information":[{"code":"090","type":"MS-DRG"},{"code":"123","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC A ","code_information":[{"code":"063","type":"MS-DRG"},{"code":"140","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Addition to lower extremity, knee disarticulation, leather socket ","code_information":[{"code":"L5640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":613.98,"maximum":1341.46,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":782.82,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1341.46,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":782.82,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":782.82,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":767.47,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":744.45,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":613.98,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":798.17,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":752.12,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":771.31,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":767.47,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":767.47,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":798.17,"methodology":"fee schedule"}]}]},{"description":"Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm ","code_information":[{"code":"13151","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Open treatment of knee dislocation, includes internal fixation, when performed; without primary ligamentous repair or augmentation/reconstruction ","code_information":[{"code":"27556","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Vasopressin (antidiuretic hormone, ADH) ","code_information":[{"code":"36861","type":"CDM"},{"code":"84588","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.15,"maximum":144.54,"gross_charge":1492.00,"discounted_cash":1492.00,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":30.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":34.62,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":59.32,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":144.54,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":144.50,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":34.62,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":34.62,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":110.07,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":125.08,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":100.07,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":125.08,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":95.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":33.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":34.04,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":27.15,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":35.30,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":34.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":34.11,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":33.94,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":33.94,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":31.12,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":35.30,"methodology":"fee schedule"}]}]},{"description":"Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) ","code_information":[{"code":"27602","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Closed treatment of calcaneal fracture; without manipulation ","code_information":[{"code":"28400","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"BONE DISEASES AND ARTHROPATHIES WITHOUT MCC ","code_information":[{"code":"137","type":"RC"},{"code":"554","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate ","code_information":[{"code":"309","type":"RC"},{"code":"87046","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.53,"maximum":36.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.82,"methodology":"fee schedule"}]}]},{"description":"OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC ","code_information":[{"code":"790","type":"RC"},{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Laryngoscopy direct, with or without tracheoscopy; with dilation, initial ","code_information":[{"code":"31528","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area o ","code_information":[{"code":"369","type":"RC"},{"code":"69716","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"PERIPHERAL VASCULAR DISORDERS WITH MCC ","code_information":[{"code":"146","type":"RC"},{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only ","code_information":[{"code":"L2800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":128.18,"maximum":280.07,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":163.43,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":280.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":163.43,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":163.43,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":160.23,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":155.42,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":128.18,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":166.64,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":157.03,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":161.03,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":160.23,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":160.23,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":166.64,"methodology":"fee schedule"}]}]},{"description":"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NEC ","code_information":[{"code":"004","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Inj, adalimumab, 1 mg ","code_information":[{"code":"817","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":73.38,"maximum":160.33,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":93.56,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":160.33,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":93.56,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":93.56,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":91.72,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":73.38,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":95.39,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":92.18,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":91.72,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":91.72,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":95.39,"methodology":"fee schedule"}]}]},{"description":"Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures) ","code_information":[{"code":"33548","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Blood typing, serologic; antigen screening for compatible unit using patient serum, per unit screened ","code_information":[{"code":"303","type":"RC"},{"code":"86904","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.88,"maximum":63.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":62.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":63.73,"methodology":"fee schedule"}]}]},{"description":"Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level ","code_information":[{"code":"22869","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":42017.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":42017.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":42017.90,"methodology":"case rate"}]}]},{"description":"Computed tomography, thorax, diagnostic; without contrast material ","code_information":[{"code":"400","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":442.55,"maximum":491.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":442.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":488.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":491.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":491.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":488.19,"methodology":"fee schedule"}]}]},{"description":"Repair of symblepharon; conjunctivoplasty, without graft ","code_information":[{"code":"499","type":"RC"},{"code":"68330","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Actin (smooth muscle) antibody (ASMA), each ","code_information":[{"code":"309","type":"RC"},{"code":"86015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.97,"maximum":44.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":44.97,"methodology":"fee schedule"}]}]},{"description":"Cystectomy, partial; simple ","code_information":[{"code":"481","type":"RC"},{"code":"51550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thoracoscopy, surgical; with removal of two lobes (bilobectomy) ","code_information":[{"code":"32670","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Incision of lingual frenum (frenotomy) ","code_information":[{"code":"41010","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Rhinoplasty, primary; including major septal repair ","code_information":[{"code":"30420","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use ","code_information":[{"code":"128506","type":"CDM"},{"code":"90673","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":0.01,"maximum":220.35,"gross_charge":269.00,"discounted_cash":269.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":0.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":0.02,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":220.35,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":220.35,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":101.56,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":115.40,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":92.32,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":115.40,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":80.99,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":81.82,"methodology":"fee schedule"}]}]},{"description":"Fully-reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests ","code_information":[{"code":"E1050","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":96.77,"maximum":211.43,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":123.38,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":211.43,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":123.38,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":123.38,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":120.96,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":117.33,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":96.77,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":125.80,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":118.54,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":121.56,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":120.96,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":120.96,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":125.80,"methodology":"fee schedule"}]}]},{"description":"Oncology (prostate), augmentative algorighmic analysis of digitized whole-slide imaging of histologic features for microsatellite instability (MSI) and homologous recombination deficience (HRD) status ","code_information":[{"code":"0513U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1161.78,"maximum":2754.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1161.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2714.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1291.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1291.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2754.38,"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":821.83,"maximum":912.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":821.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":906.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":912.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":912.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":906.58,"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":"81212","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":352.00,"maximum":1873.87,"payers_information":[{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":392.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":448.80,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":769.08,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1873.87,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1873.30,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":448.80,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":448.80,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1284.32,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":1459.44,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1167.58,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":1459.44,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":1118.70,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":440.00,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":352.00,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":457.60,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":442.20,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":440.00,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":440.00,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":403.44,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":457.60,"methodology":"fee schedule"}]}]},{"description":"Unlisted laparoscopic procedure, liver ","code_information":[{"code":"369","type":"RC"},{"code":"47379","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Maxillary impression for palatal prosthesis ","code_information":[{"code":"42280","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Correction claw finger, other methods ","code_information":[{"code":"26499","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Submucosal cryolysis therapy; base of tongue and lingual tonsil only ","code_information":[{"code":"0980T","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Orbital implant (implant outside muscle cone); removal or revision ","code_information":[{"code":"360","type":"RC"},{"code":"67560","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices ","code_information":[{"code":"361","type":"RC"},{"code":"43243","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Closure of enterovesical fistula; without intestinal or bladder resection ","code_information":[{"code":"369","type":"RC"},{"code":"44660","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral ","code_information":[{"code":"322","type":"RC"},{"code":"77066","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":236.13,"maximum":262.32,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":236.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":260.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":262.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":262.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":260.48,"methodology":"fee schedule"}]}]},{"description":"Periodontal mucosal grafting ","code_information":[{"code":"41870","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Lipoprotein, blood; quantitation of lipoprotein particle number(s) (eg, by nuclear magnetic resonance spectroscopy), includes lipoprotein particle subclass(es), when performed ","code_information":[{"code":"83704","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":56.24,"maximum":133.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":56.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":131.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":62.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":62.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":133.34,"methodology":"fee schedule"}]}]},{"description":"MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. ","code_information":[{"code":"481","type":"RC"},{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DISORDERS OF THE BILIARY TRACT WITH CC ","code_information":[{"code":"150","type":"RC"},{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation ","code_information":[{"code":"323","type":"RC"},{"code":"74329","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":116.52,"maximum":129.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":116.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":128.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":129.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":129.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":128.54,"methodology":"fee schedule"}]}]},{"description":"Application, cast; plaster Velpeau ","code_information":[{"code":"29058","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel ","code_information":[{"code":"409","type":"RC"},{"code":"77770","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":1291.89,"maximum":1435.15,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1291.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1425.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1435.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1435.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1425.10,"methodology":"fee schedule"}]}]},{"description":"Angiography, spinal, selective, radiological supervision and interpretation ","code_information":[{"code":"320","type":"RC"},{"code":"75705","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":580.51,"maximum":644.89,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":580.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":640.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":644.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":644.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":640.37,"methodology":"fee schedule"}]}]},{"description":"Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula ","code_information":[{"code":"23172","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each ","code_information":[{"code":"26727","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Gradient compression stocking, waist length, 30-40 mmhg, each ","code_information":[{"code":"A6540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":90.89,"maximum":198.58,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":115.88,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":198.58,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":115.88,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":115.88,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":113.61,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":110.20,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":90.89,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":118.15,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":111.34,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":114.18,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":113.61,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":113.61,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":118.15,"methodology":"fee schedule"}]}]},{"description":"FRACTURES OF HIP AND PELVIS WITH MCC ","code_information":[{"code":"143","type":"RC"},{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, hip, arthrography, radiological supervision and interpretation ","code_information":[{"code":"400","type":"RC"},{"code":"73525","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":139.76,"maximum":155.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":139.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":154.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":155.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":155.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":154.17,"methodology":"fee schedule"}]}]},{"description":"Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intraocular retinal electrode array, with vitrectomy ","code_information":[{"code":"0100T","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Fetal scalp blood sampling ","code_information":[{"code":"59030","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"NERVOUS SYSTEM NEOPLASMS WITH MCC ","code_information":[{"code":"054","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy, soft tissue of neck or thorax ","code_information":[{"code":"21550","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":2868.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"IDH1, IDH2, and TERT promoter (eg, central nervous system tumors), next-generatin sequencing (single-nucleotide variants (SNV), deletions, and insertions) ","code_information":[{"code":"0481U","type":"CPT"},{"code":"305","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1109.12,"maximum":2629.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1109.12,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2591.78,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1232.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1232.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2629.54,"methodology":"fee schedule"}]}]},{"description":"NEUROSES EXCEPT DEPRESSIVE  IPF","code_information":[{"code":"144","type":"RC"},{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1014.23,"maximum":1034.51,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1034.51,"methodology":"fee schedule","additional_payer_notes":"Days 8. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1014.23,"methodology":"fee schedule","additional_payer_notes":"Days 8. "}]}]},{"description":"Colporrhaphy, suture of injury of vagina (nonobstetrical) ","code_information":[{"code":"361","type":"RC"},{"code":"57200","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"53460","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Chemodenervation of internal anal sphincter ","code_information":[{"code":"369","type":"RC"},{"code":"46505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Cineradiography/videoradiography, except where specifically included ","code_information":[{"code":"323","type":"RC"},{"code":"76120","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":572.03,"maximum":635.47,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":572.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":631.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":635.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":635.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":631.01,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, spine; thoracic, minimum of 4 views ","code_information":[{"code":"324","type":"RC"},{"code":"72074","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":59.01,"maximum":65.55,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":59.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":65.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":65.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":65.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.09,"methodology":"fee schedule"}]}]},{"description":"Excision of tendon, finger, flexor or extensor, each tendon ","code_information":[{"code":"26180","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"RESPIRATORY NEOPLASMS WITHOUT CC/MCC ","code_information":[{"code":"123","type":"RC"},{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"0652T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"}]}]},{"description":"Revision mastoidectomy; resulting in radical mastoidectomy ","code_information":[{"code":"369","type":"RC"},{"code":"69603","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Transcatheter implantation of coronary sinus reduction device including vascular access and closure, right heart catheterization, venous angiography, coronary sinus angiography, imaging guidance, and ","code_information":[{"code":"0645T","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21416.00,"maximum":25567.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":21416.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":25567.00,"methodology":"case rate"}]}]},{"description":"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC ","code_information":[{"code":"127","type":"RC"},{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space ","code_information":[{"code":"361","type":"RC"},{"code":"41008","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Exploration for undescended testis (inguinal or scrotal area) ","code_information":[{"code":"361","type":"RC"},{"code":"54550","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"72149","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":425.85,"maximum":473.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":425.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":469.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":473.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":473.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":469.76,"methodology":"fee schedule"}]}]},{"description":"FOOT PROCEDURES WITH CC ","code_information":[{"code":"481","type":"RC"},{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC ","code_information":[{"code":"209","type":"RC"},{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9 ","code_information":[{"code":"300","type":"RC"},{"code":"81219","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":200.08,"maximum":474.36,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":200.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":467.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":222.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":222.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":474.36,"methodology":"fee schedule"}]}]},{"description":"Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation ","code_information":[{"code":"27256","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC ","code_information":[{"code":"154","type":"RC"},{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of distal fibular fracture (lateral malleolus); with manipulation ","code_information":[{"code":"27788","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Osmolality; urine ","code_information":[{"code":"306","type":"RC"},{"code":"83935","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11.22,"maximum":26.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":26.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":12.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":12.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":26.60,"methodology":"fee schedule"}]}]},{"description":"Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm ","code_information":[{"code":"11424","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Removal of lung, other than pneumonectomy; single segment (segmentectomy) ","code_information":[{"code":"32484","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure) ","code_information":[{"code":"32551","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Craniectomy for craniosynostosis; single cranial suture ","code_information":[{"code":"61550","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL OBSTRUCTION WITH MCC ","code_information":[{"code":"157","type":"RC"},{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed ","code_information":[{"code":"28615","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Dissection, deep jugular node(s) ","code_information":[{"code":"38542","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Biopsy of liver, needle; percutaneous ","code_information":[{"code":"47000","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Radiopharmaceutical dacryocystography ","code_information":[{"code":"342","type":"RC"},{"code":"78660","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":577.99,"maximum":642.09,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":577.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":637.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":642.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":642.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":637.59,"methodology":"fee schedule"}]}]},{"description":"Removal of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure) ","code_information":[{"code":"20703","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children ","code_information":[{"code":"15273","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH CC ","code_information":[{"code":"138","type":"RC"},{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Aspiration and injection for treatment of bone cyst ","code_information":[{"code":"20615","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":2592.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) ","code_information":[{"code":"31622","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"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":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) ","code_information":[{"code":"64629","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Drug metabolism or processing (mult conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes ","code_information":[{"code":"0350U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2197.87,"maximum":5210.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":2197.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5135.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":2442.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":2442.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5210.75,"methodology":"fee schedule"}]}]},{"description":"Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure) ","code_information":[{"code":"360","type":"RC"},{"code":"44015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad ","code_information":[{"code":"15838","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Management of recipient hematopoietic progenitor cell donor search and cell acquisition ","code_information":[{"code":"38204","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthrotomy, knee; with synovial biopsy only ","code_information":[{"code":"27330","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"156","type":"RC"},{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft ","code_information":[{"code":"24342","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Vitamin A ","code_information":[{"code":"84590","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":19.10,"maximum":45.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":19.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":44.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":21.22,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":45.28,"methodology":"fee schedule"}]}]},{"description":"Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) ","code_information":[{"code":"65600","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy an ","code_information":[{"code":"750","type":"RC"},{"code":"92944","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12481.00,"maximum":21869.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12481.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21869.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21869.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Osteotomy; tibia ","code_information":[{"code":"27705","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Bypass graft, with other than vein; axillary-femoral-femoral ","code_information":[{"code":"35654","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum) ","code_information":[{"code":"44700","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Convert nephrostomy catheter to nephroureteral catheter, percutaneous via pre-existing nephrostomy tract, with ureteral stricture balloon dialation, including diagnostic nephrostogram and/or ureterogr ","code_information":[{"code":"499","type":"RC"},{"code":"C7547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique ","code_information":[{"code":"305","type":"RC"},{"code":"87495","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":49.40,"maximum":117.12,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":49.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":115.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":54.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":54.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":117.12,"methodology":"fee schedule"}]}]},{"description":"Decompression facial nerve, intratemporal; lateral to geniculate ganglion ","code_information":[{"code":"360","type":"RC"},{"code":"69720","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC ","code_information":[{"code":"137","type":"RC"},{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Salivary gland function study ","code_information":[{"code":"342","type":"RC"},{"code":"78232","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":94.16,"maximum":104.61,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":94.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":103.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":104.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":104.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":103.87,"methodology":"fee schedule"}]}]},{"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":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Haloperidol ","code_information":[{"code":"301","type":"RC"},{"code":"37028","type":"CDM"},{"code":"80173","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":25.96,"maximum":61.54,"gross_charge":823.75,"discounted_cash":823.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":25.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":60.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":28.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":28.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":61.54,"methodology":"fee schedule"}]}]},{"description":"Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy) ","code_information":[{"code":"51565","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Injection, cangrelor, 1 mg ","code_information":[{"code":"C9460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":21.53,"maximum":52.22,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":22.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.68,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":34.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":52.22,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":52.22,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":23.68,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":26.91,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":21.53,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":26.91,"methodology":"fee schedule"}]}]},{"description":"Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure) ","code_information":[{"code":"361","type":"RC"},{"code":"93623","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":29614.00,"maximum":51885.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":29614.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":32904.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":51885.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Immunoassay for infectious agent antibody, quantitative, not otherwise specified ","code_information":[{"code":"86317","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":24.66,"maximum":58.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.46,"methodology":"fee schedule"}]}]},{"description":"Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx ","code_information":[{"code":"369","type":"RC"},{"code":"42815","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Bronchoplasty; graft repair ","code_information":[{"code":"31770","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"DIGESTIVE MALIGNANCY WITH MCC ","code_information":[{"code":"133","type":"RC"},{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Pooling of platelets or other blood products ","code_information":[{"code":"305","type":"RC"},{"code":"86965","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal em ","code_information":[{"code":"369","type":"RC"},{"code":"37215","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12481.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21869.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21869.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Pregnancy-associated plasma protein-A (PAPP-A) ","code_information":[{"code":"305","type":"RC"},{"code":"84163","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":24.76,"maximum":58.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":24.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":57.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":27.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":27.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":58.70,"methodology":"fee schedule"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC ","code_information":[{"code":"074","type":"MS-DRG"},{"code":"214","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with insertion ","code_information":[{"code":"369","type":"RC"},{"code":"66991","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":42495.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":35253.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":42495.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Storage (per year); embryo(s) ","code_information":[{"code":"306","type":"RC"},{"code":"89342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Antibody elution (RBC), each elution ","code_information":[{"code":"301","type":"RC"},{"code":"86860","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":245.37,"maximum":581.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":245.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":573.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":272.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":581.72,"methodology":"fee schedule"}]}]},{"description":"Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness ","code_information":[{"code":"369","type":"RC"},{"code":"67930","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Infectious disease, bacterial vaginosis and vaginitis, real-time PCR amplification of DNA markers for Atopobium vaginae, Atopobium species, Megasphaera type 1, and Bacterial Vaginosis Associated Bacte ","code_information":[{"code":"309","type":"RC"},{"code":"81515","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":432.62,"maximum":1025.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":432.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1010.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":480.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":480.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1025.66,"methodology":"fee schedule"}]}]},{"description":"Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without ","code_information":[{"code":"L5683","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":1239.92,"maximum":2709.07,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":1580.90,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":2709.07,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":1580.90,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1580.90,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":1549.90,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":1503.40,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1239.92,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":1611.90,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":1518.90,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":1557.65,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":1549.90,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":1549.90,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":1611.90,"methodology":"fee schedule"}]}]},{"description":"Radiologic examination, skull; less than 4 views ","code_information":[{"code":"323","type":"RC"},{"code":"70250","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":186.99,"maximum":207.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":186.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":206.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":207.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":207.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":206.27,"methodology":"fee schedule"}]}]},{"description":"Addition to lower extremity orthosis, plating chrome or nickel, per bar ","code_information":[{"code":"L2750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":100.44,"maximum":219.45,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":128.06,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":219.45,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":128.06,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":128.06,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":125.55,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":121.78,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":100.44,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":130.57,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":123.04,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":126.18,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":125.55,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":125.55,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":130.57,"methodology":"fee schedule"}]}]},{"description":"PULMONARY EDEMA AND RESPIRATORY FAILURE ","code_information":[{"code":"189","type":"MS-DRG"},{"code":"208","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy, pleura, percutaneous needle ","code_information":[{"code":"32400","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart ","code_information":[{"code":"303","type":"RC"},{"code":"87084","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.53,"maximum":105.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":104.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":49.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":49.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":105.57,"methodology":"fee schedule"}]}]},{"description":"CHEST PAIN ","code_information":[{"code":"203","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage ","code_information":[{"code":"31238","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"New Technology - Level 22 ","code_information":[{"code":"1522","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":1960.82,"maximum":4284.14,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":2500.04,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":4284.14,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":2500.04,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":2500.04,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":2451.02,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":1960.82,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":2549.06,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":2463.28,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":2451.02,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":2451.02,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":2549.06,"methodology":"fee schedule"}]}]},{"description":"TRANSURETHRAL PROCEDURES WITH CC ","code_information":[{"code":"369","type":"RC"},{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Biopsy, prostate; incisional, any approach ","code_information":[{"code":"499","type":"RC"},{"code":"55705","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC ","code_information":[{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1685.00,"maximum":80699.40,"payers_information":[{"payer_name":"Aetna","plan_name":"EPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":101709.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"HMO","standard_charge_percentage":59.50,"standard_charge_algorithm":"Reimbursement will be 59.5% of billable gross charges.","estimated_amount":90594.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"POS","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":101709.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Aetna","plan_name":"PPO","standard_charge_percentage":66.80,"standard_charge_algorithm":"Reimbursement will be 66.8% of billable gross charges.","estimated_amount":101709.850,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"AmeriHealth Caritas","plan_name":"MCD","standard_charge_dollar":18207.25,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21742.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":80699.40,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24158.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_percentage":46.60,"standard_charge_algorithm":"Reimbursement will be 46.6% of billable gross charges.","estimated_amount":70953.280,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":23826.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24158.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65374.06,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":35633.54,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30166.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":34690.00,"methodology":"case rate"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":23826.97,"methodology":"fee schedule"},{"payer_name":"CorVel","plan_name":"WorkersComp","standard_charge_percentage":72.00,"standard_charge_algorithm":"Reimbursement will be 72% of billable gross charges.","estimated_amount":109627.380,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"EverNorth","plan_name":"COMM","standard_charge_percentage":80.00,"standard_charge_algorithm":"Reimbursement will be 80% of billable gross charges.","estimated_amount":121808.200,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"First Health","plan_name":"PPO","standard_charge_dollar":1685.00,"methodology":"per diem"},{"payer_name":"Granite State Health","plan_name":"MGMCD","standard_charge_dollar":17853.71,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_percentage":22.00,"standard_charge_algorithm":"Reimbursement will be 22% of billable gross charges.","estimated_amount":33497.250,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":38080.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_percentage":20.00,"standard_charge_algorithm":"Reimbursement will be 20% of billable gross charges.","estimated_amount":30452.050,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_percentage":25.01,"standard_charge_algorithm":"Reimbursement will be 25.01% of billable gross charges.","estimated_amount":38080.290,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_percentage":45.01,"standard_charge_algorithm":"Reimbursement will be 45.01% of billable gross charges.","estimated_amount":68532.340,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Healthcare Value Mgmt","plan_name":"COMM","standard_charge_dollar":2350.00,"methodology":"per diem"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":23359.77,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":18687.82,"methodology":"fee schedule"},{"payer_name":"Maine Community Health","plan_name":"Individual","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":43637.790,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"LargeGroup","standard_charge_percentage":52.99,"standard_charge_algorithm":"Reimbursement will be 52.99% of billable gross charges.","estimated_amount":80682.710,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Maine Community Health","plan_name":"SmallGroup","standard_charge_percentage":28.66,"standard_charge_algorithm":"Reimbursement will be 28.66% of billable gross charges.","estimated_amount":43637.790,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":24294.16,"methodology":"fee schedule"},{"payer_name":"Oxford Health Plans","plan_name":"COMM","standard_charge_percentage":95.00,"standard_charge_algorithm":"Reimbursement will be 95% of billable gross charges.","estimated_amount":144647.240,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5740.00,"methodology":"per diem"},{"payer_name":"United","plan_name":"AllPayerAppendix","standard_charge_percentage":42.60,"standard_charge_algorithm":"Reimbursement will be 42.6% of billable gross charges.","estimated_amount":64862.870,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"FreedomBenefitPlans","standard_charge_percentage":26.70,"standard_charge_algorithm":"Reimbursement will be 26.7% of billable gross charges.","estimated_amount":40653.490,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":22518.82,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"OptionsPPO","standard_charge_percentage":61.30,"standard_charge_algorithm":"Reimbursement will be 61.3% of billable gross charges.","estimated_amount":93335.530,"methodology":"percent of total billed charges","additional_payer_notes":" Zero instances of the item or service in the last 12 months prior to the posting."},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":23359.77,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":23359.77,"methodology":"fee schedule"},{"payer_name":"Well Sense Health Plan","plan_name":"MCD","standard_charge_dollar":19002.71,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":24060.56,"methodology":"fee schedule"}]}]},{"description":"Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species ","code_information":[{"code":"303","type":"RC"},{"code":"87045","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":15.53,"maximum":36.82,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":15.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":36.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":36.82,"methodology":"fee schedule"}]}]},{"description":"Luteinizing releasing factor (LRH) ","code_information":[{"code":"303","type":"RC"},{"code":"83727","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":28.28,"maximum":67.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":28.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":66.08,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":31.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":31.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":67.04,"methodology":"fee schedule"}]}]},{"description":"TRAUMATIC INJURY WITHOUT MCC ","code_information":[{"code":"914","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":5293.37,"maximum":5347.94,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":5293.37,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":5347.94,"methodology":"fee schedule"}]}]},{"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":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Ablation, open, of 1 or more liver tumor(s); cryosurgical ","code_information":[{"code":"47381","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studie ","code_information":[{"code":"341","type":"RC"},{"code":"73436","type":"CDM"},{"code":"78454","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":1718.71,"maximum":1909.31,"gross_charge":7568.25,"discounted_cash":7568.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1718.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1895.93,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1909.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1909.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1895.93,"methodology":"fee schedule"}]}]},{"description":"Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; and distal femur ","code_information":[{"code":"27742","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability ºXLID») gene analysis; evaluation to detect abnormal (eg, expanded) alleles ","code_information":[{"code":"305","type":"RC"},{"code":"81243","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":93.83,"maximum":222.46,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":93.83,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":219.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":104.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":104.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":222.46,"methodology":"fee schedule"}]}]},{"description":"Antibody; actinomyces ","code_information":[{"code":"304","type":"RC"},{"code":"86602","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.75,"maximum":39.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":39.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":39.70,"methodology":"fee schedule"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism ","code_information":[{"code":"301","type":"RC"},{"code":"87299","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.48,"maximum":62.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.79,"methodology":"fee schedule"}]}]},{"description":"Exclusion of left atrial appendage, thoracoscopic, any method (eg, excision, isolation via stapling, oversewing, ligation, plication, clip) ","code_information":[{"code":"33269","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OSTEOMYELITIS WITH CC ","code_information":[{"code":"136","type":"RC"},{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Incision and drainage, forearm and/or wrist; deep abscess or hematoma ","code_information":[{"code":"25028","type":"CPT"},{"code":"361","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space ","code_information":[{"code":"361","type":"RC"},{"code":"41007","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Simple cystometrogram (CMG) (eg, spinal manometer) ","code_information":[{"code":"499","type":"RC"},{"code":"51725","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Estrogens; fractionated ","code_information":[{"code":"82671","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":53.13,"maximum":125.97,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":53.13,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":124.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":59.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":59.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":125.97,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy with insertion of temporary device for ischemic remodeling (ie, pressure necrosis) of bladder neck and prostate ","code_information":[{"code":"53865","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"126","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":1113.66,"maximum":1113.66,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":1113.66,"methodology":"fee schedule","additional_payer_notes":"Days 4. "}]}]},{"description":"Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm ","code_information":[{"code":"21011","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Drug metabolism, psychiatry (eg major depressive disorder, general anxiety disorder, ADHD, schizophrenia), whole blood, buccal swab, and pharmacogenomic genotyping of 14 genes and CYP2D6 copy number v ","code_information":[{"code":"0476U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":685.60,"maximum":1625.44,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":685.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1602.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":761.87,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1625.44,"methodology":"fee schedule"}]}]},{"description":"Drug test(s), definitive, 90 or more drugs or substances, definitive chromatography with mass spectrometry, and presumptive, any number of drug classes, by instrument chemistry analyzer (utilizing imm ","code_information":[{"code":"0082U","type":"CPT"},{"code":"306","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":406.18,"maximum":962.99,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":406.18,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":949.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":451.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":451.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":962.99,"methodology":"fee schedule"}]}]},{"description":"Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed ","code_information":[{"code":"46948","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access ","code_information":[{"code":"36595","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4667.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Arthroscopy, knee, surgical; for infection, lavage and drainage ","code_information":[{"code":"29871","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":5855.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) ABCA4 (ATP-binding cassette, sub-family A ºABC1», member 4) (eg, Stargardt disease, age-rel ","code_information":[{"code":"303","type":"RC"},{"code":"81408","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3290.00,"maximum":7800.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3290.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":7688.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3656.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3656.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":7800.00,"methodology":"fee schedule"}]}]},{"description":"Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon ","code_information":[{"code":"26370","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Removal of corneal epithelium; with application of chelating agent (eg, EDTA) ","code_information":[{"code":"490","type":"RC"},{"code":"65436","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"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; w ","code_information":[{"code":"490","type":"RC"},{"code":"59857","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Sperm identification from testis tissue, fresh or cryopreserved ","code_information":[{"code":"305","type":"RC"},{"code":"89264","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":81.86,"maximum":194.06,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":81.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":191.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":90.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":194.06,"methodology":"fee schedule"}]}]},{"description":"Semen analysis; presence and/or motility of sperm including Huhner test (post coital) ","code_information":[{"code":"301","type":"RC"},{"code":"89300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.19,"maximum":38.38,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":37.82,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":17.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":17.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":38.38,"methodology":"fee schedule"}]}]},{"description":"Reopening of recent laparotomy ","code_information":[{"code":"49002","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC ","code_information":[{"code":"448","type":"MS-DRG"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar ","code_information":[{"code":"22102","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC ","code_information":[{"code":"481","type":"RC"},{"code":"717","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, teeth; single view ","code_information":[{"code":"324","type":"RC"},{"code":"70300","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":68.52,"maximum":76.11,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":68.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":75.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":76.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":76.11,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":75.58,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of mandibular fracture; without manipulation ","code_information":[{"code":"21450","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC ","code_information":[{"code":"100","type":"RC"},{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Unlisted procedure, Meckel's diverticulum and the mesentery ","code_information":[{"code":"361","type":"RC"},{"code":"44899","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Excision of carotid body tumor; without excision of carotid artery ","code_information":[{"code":"481","type":"RC"},{"code":"60600","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Removal of prosthesis, includes debridement and synovectomy when performed; radial head ","code_information":[{"code":"24164","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"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":"321","type":"RC"},{"code":"77767","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":283.01,"maximum":314.39,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":283.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":312.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":314.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":314.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":312.19,"methodology":"fee schedule"}]}]},{"description":"Incision, anal septum (infant) ","code_information":[{"code":"46070","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"GASTROINTESTINAL HEMORRHAGE WITH MCC ","code_information":[{"code":"207","type":"RC"},{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Antibody; fungus, not elsewhere specified ","code_information":[{"code":"301","type":"RC"},{"code":"86671","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":20.15,"maximum":47.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":20.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":47.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":22.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":22.39,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":47.77,"methodology":"fee schedule"}]}]},{"description":"FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY ","code_information":[{"code":"143","type":"RC"},{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) ","code_information":[{"code":"360","type":"RC"},{"code":"45342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC ","code_information":[{"code":"164","type":"RC"},{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC ","code_information":[{"code":"056","type":"MS-DRG"},{"code":"206","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC ","code_information":[{"code":"167","type":"RC"},{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC ","code_information":[{"code":"111","type":"RC"},{"code":"699","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC ","code_information":[{"code":"117","type":"RC"},{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oophorectomy, partial or total, unilateral or bilateral; ","code_information":[{"code":"481","type":"RC"},{"code":"58940","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":11152.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion Radiation Therapy","code_information":[{"code":"333","type":"RC"},{"code":"63620","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":975.00,"maximum":2067.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":975.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2067.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1083.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1083.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2067.00,"methodology":"case rate"}]}]},{"description":"Level 4 Neurostimulator an ","code_information":[{"code":"05464","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":22654.44,"maximum":22887.99,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":22654.44,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":22887.99,"methodology":"fee schedule"}]}]},{"description":"Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel ","code_information":[{"code":"0237T","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insertion of penile prosthesis; inflatable (self-contained) ","code_information":[{"code":"54401","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC ","code_information":[{"code":"144","type":"RC"},{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Incision, bone cortex (eg, osteomyelitis or bone abscess), foot ","code_information":[{"code":"28005","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":18478.00,"maximum":22274.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"}]}]},{"description":"Bile acids; cholylglycine ","code_information":[{"code":"307","type":"RC"},{"code":"82240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":43.72,"maximum":103.66,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":43.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":102.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":48.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":48.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":103.66,"methodology":"fee schedule"}]}]},{"description":"Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure) ","code_information":[{"code":"0133U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1135.53,"maximum":2692.13,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1135.53,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2653.47,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1261.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1261.85,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2692.13,"methodology":"fee schedule"}]}]},{"description":"Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation ","code_information":[{"code":"322","type":"RC"},{"code":"75741","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":297.09,"maximum":330.04,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":297.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":327.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":330.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":330.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":327.73,"methodology":"fee schedule"}]}]},{"description":"Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) ","code_information":[{"code":"319","type":"RC"},{"code":"88350","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":133.74,"maximum":317.07,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":133.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":312.52,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":148.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":148.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":317.07,"methodology":"fee schedule"}]}]},{"description":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC ","code_information":[{"code":"131","type":"RC"},{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thyroid stimulating hormone (TSH) ","code_information":[{"code":"303","type":"RC"},{"code":"84443","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":27.64,"maximum":65.52,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":27.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":64.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":30.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":30.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":65.52,"methodology":"fee schedule"}]}]},{"description":"Lateral canthopexy ","code_information":[{"code":"21282","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":31314.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":25978.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":31314.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"TRAUMATIC INJURY WITH MCC ","code_information":[{"code":"141","type":"RC"},{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Anoscopy; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique ","code_information":[{"code":"360","type":"RC"},{"code":"46612","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Open treatment of carpal bone fracture (other than carpal scaphoid ºnavicular»), each bone ","code_information":[{"code":"25645","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) fo ","code_information":[{"code":"31654","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":7032.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) ","code_information":[{"code":"27422","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) ","code_information":[{"code":"38505","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less ","code_information":[{"code":"369","type":"RC"},{"code":"49203","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Unlisted laparoscopy procedure, biliary tract ","code_information":[{"code":"360","type":"RC"},{"code":"47579","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Ligation of peritoneal-venous shunt ","code_information":[{"code":"49428","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1441.04,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":1441.05,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":1441.04,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"71550","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":1422.24,"maximum":1579.96,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1422.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1568.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1579.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1579.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1568.89,"methodology":"fee schedule"}]}]},{"description":"Orbitotomy without bone flap (frontal or transconjunctival approach); with drainage only ","code_information":[{"code":"360","type":"RC"},{"code":"67405","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion of ventricular assist device; extracorporeal, single ventricle ","code_information":[{"code":"33975","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds ","code_information":[{"code":"52400","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Insertion of intra-aortic balloon assist device, percutaneous ","code_information":[{"code":"33967","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) ","code_information":[{"code":"0268T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":10335.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls ","code_information":[{"code":"369","type":"RC"},{"code":"42892","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"description":"Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin) ","code_information":[{"code":"361","type":"RC"},{"code":"43510","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH ","code_information":[{"code":"410","type":"MS-DRG"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Level 5 ENT Procedures ","code_information":[{"code":"05165","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":6249.46,"maximum":6313.89,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":6249.46,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":6313.89,"methodology":"fee schedule"}]}]},{"description":"Technetium tc-99m oxidronate, diagnostic, per study dose, up to 30 millicuries ","code_information":[{"code":"A9561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":49.62,"maximum":120.37,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":120.37,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":120.37,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":54.59,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":62.02,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":49.62,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":62.02,"methodology":"fee schedule"}]}]},{"description":"Repair oval window fistula ","code_information":[{"code":"360","type":"RC"},{"code":"69666","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopi ","code_information":[{"code":"33964","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Endovascular placement of iliac artery occlusion device (List separately in addition to code for primary procedure) ","code_information":[{"code":"34808","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC ","code_information":[{"code":"156","type":"MS-DRG"},{"code":"204","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"DENTAL AND ORAL DISEASES WITH CC ","code_information":[{"code":"158","type":"MS-DRG"},{"code":"207","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thoracoscopy, surgical; with total pulmonary decortication, including intrapleural pneumonolysis ","code_information":[{"code":"32652","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or b ","code_information":[{"code":"22515","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Tiagabine ","code_information":[{"code":"80199","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":44.60,"maximum":105.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":104.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":49.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":49.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":105.73,"methodology":"fee schedule"}]}]},{"description":"OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC ","code_information":[{"code":"717","type":"MS-DRG"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Revision of colostomy; complicated (reconstruction in-depth) (separate procedure) ","code_information":[{"code":"44345","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Exploration of penetrating wound (separate procedure); abdomen/flank/back ","code_information":[{"code":"20102","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Revision or removal of gastric neurostimulator electrodes, antrum, open ","code_information":[{"code":"361","type":"RC"},{"code":"43882","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass ","code_information":[{"code":"33983","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Ablation of benign prostate tissue, transrectal, with high intensity?focused ultrasound (HIFU), including ultrasound guidance ","code_information":[{"code":"0950T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":19041.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Thyroidectomy, total or complete ","code_information":[{"code":"361","type":"RC"},{"code":"60240","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Injection, fosnetupitant 235 mg and palonosetron 0.25 mg ","code_information":[{"code":"J1454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":613.89,"maximum":1765.02,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":896.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1030.72,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":996.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":819.01,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":996.37,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1230.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":1765.02,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":1765.02,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":800.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":909.49,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":727.60,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":909.49,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":613.89,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":620.22,"methodology":"fee schedule"}]}]},{"description":"Submucous resection inferior turbinate, partial or complete, any method ","code_information":[{"code":"30140","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":5383.60,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC ","code_information":[{"code":"498","type":"MS-DRG"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Muscle transfer, any type, shoulder or upper arm; multiple ","code_information":[{"code":"23397","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"VIRAL ILLNESS WITHOUT MCC ","code_information":[{"code":"143","type":"RC"},{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Radiologic examination, mastoids; complete, minimum of 3 views per side ","code_information":[{"code":"400","type":"RC"},{"code":"70130","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":82.50,"maximum":91.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":82.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":91.00,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":91.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":91.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":91.00,"methodology":"fee schedule"}]}]},{"description":"Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique ","code_information":[{"code":"340","type":"RC"},{"code":"78468","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":756.56,"maximum":840.45,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":756.56,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":834.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":840.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":840.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":834.57,"methodology":"fee schedule"}]}]},{"description":"Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation ","code_information":[{"code":"25660","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1284.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1284.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2592.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1427.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2220.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) ","code_information":[{"code":"20979","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique ","code_information":[{"code":"309","type":"RC"},{"code":"87490","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.42,"maximum":88.72,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":37.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":87.45,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":41.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":88.72,"methodology":"fee schedule"}]}]},{"description":"Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50- 100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psor ","code_information":[{"code":"0258U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6045.38,"maximum":14332.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6045.38,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14126.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":6717.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":6717.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":14332.50,"methodology":"fee schedule"}]}]},{"description":"Excision of chalazion; single ","code_information":[{"code":"67800","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":5003.00,"maximum":6031.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"}]}]},{"description":"Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent ","code_information":[{"code":"305","type":"RC"},{"code":"87190","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":12.02,"maximum":28.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":12.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":28.10,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28.51,"methodology":"fee schedule"}]}]},{"description":"Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) ","code_information":[{"code":"481","type":"RC"},{"code":"52342","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":8425.41,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction ","code_information":[{"code":"69643","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) ","code_information":[{"code":"26432","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Percutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance ","code_information":[{"code":"0632T","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."}]}]},{"description":"Unlisted procedure, vascular surgery ","code_information":[{"code":"37799","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":690.90,"maximum":21862.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":10335.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":11483.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":21862.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":690.91,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":690.90,"methodology":"case rate"}]}]},{"description":"NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis ","code_information":[{"code":"304","type":"RC"},{"code":"81193","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":341.02,"maximum":808.51,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":341.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":796.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":378.96,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":808.51,"methodology":"fee schedule"}]}]},{"description":"Phototherapy (bilirubin) light with photometer ","code_information":[{"code":"E0202","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":63.95,"maximum":139.73,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":81.54,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":139.73,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":81.54,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":81.54,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":79.94,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":77.54,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":63.95,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":83.14,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":78.34,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":80.34,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":79.94,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":79.94,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":83.14,"methodology":"fee schedule"}]}]},{"description":"OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC ","code_information":[{"code":"481","type":"RC"},{"code":"674","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as ","code_information":[{"code":"306","type":"RC"},{"code":"81529","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":11832.49,"maximum":28052.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":11832.49,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":27649.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":13148.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":13148.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":28052.70,"methodology":"fee schedule"}]}]},{"description":"Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental ","code_information":[{"code":"41016","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":2258.56,"maximum":8420.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Gastric restrictive procedure, open; removal of subcutaneous port component only ","code_information":[{"code":"361","type":"RC"},{"code":"43887","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC ","code_information":[{"code":"119","type":"RC"},{"code":"178","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC ","code_information":[{"code":"110","type":"RC"},{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (solid tumor), tumor cell culture in 3D microenvironment, 36 or more drug panel, reported as tumor-response prediction for each drug ","code_information":[{"code":"0511U","type":"CPT"},{"code":"923","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4990.70,"maximum":11832.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4990.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":11662.16,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5545.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5545.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":11832.05,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, maxillofacial area; without contrast material ","code_information":[{"code":"400","type":"RC"},{"code":"70486","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":470.57,"maximum":522.75,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":470.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":519.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":522.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":522.75,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":519.09,"methodology":"fee schedule"}]}]},{"description":"Bypass graft, with vein; carotid-vertebral ","code_information":[{"code":"35508","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Insulin; total ","code_information":[{"code":"301","type":"RC"},{"code":"37064","type":"CDM"},{"code":"83525","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":18.80,"maximum":44.58,"gross_charge":405.50,"discounted_cash":405.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":18.80,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":43.94,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":20.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":44.58,"methodology":"fee schedule"}]}]},{"description":"Wheelchair with fixed arm, elevating legrests ","code_information":[{"code":"E1222","type":"HCPCS"}],"standard_charges":[{"modifiers":"RR","modifiers_description":"Rental (use the RR modifier when DME is to be rented)","setting":"outpatient","minimum":72.86,"maximum":159.20,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":92.90,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":159.20,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":92.90,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":92.90,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":91.08,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":88.35,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":72.86,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":94.72,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":89.26,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":91.54,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":91.08,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":91.08,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":94.72,"methodology":"fee schedule"}]}]},{"description":"Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and child ","code_information":[{"code":"15116","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Nephrectomy with total ureterectomy and bladder cuff; through separate incision ","code_information":[{"code":"499","type":"RC"},{"code":"50236","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"AFTERCARE WITH CC/MCC ","code_information":[{"code":"214","type":"RC"},{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery ","code_information":[{"code":"63610","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"CHEST PAIN ","code_information":[{"code":"210","type":"RC"},{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contras ","code_information":[{"code":"360","type":"RC"},{"code":"36902","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5383.60,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Injection, dalteparin sodium, per 2500 iu ","code_information":[{"code":"J1645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":15.32,"maximum":37.17,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.26,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":24.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":23.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":19.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":23.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":29.16,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":37.17,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":37.17,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":16.86,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":19.15,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":15.32,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":19.15,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":15.56,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":15.72,"methodology":"fee schedule"}]}]},{"description":"Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) ","code_information":[{"code":"38505","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Repair of omphalocele (Gross type operation); first stage ","code_information":[{"code":"49610","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Phencyclidine (PCP) ","code_information":[{"code":"307","type":"RC"},{"code":"83992","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":68.30,"maximum":161.93,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":68.30,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":159.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":75.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":75.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":161.93,"methodology":"fee schedule"}]}]},{"description":"Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed ","code_information":[{"code":"360","type":"RC"},{"code":"37226","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8425.41,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Infusion, normal saline solution , 1000 cc ","drug_information":{"unit":"1000","type":"ML"},"code_information":[{"code":"17897","type":"CDM"},{"code":"J7030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":2.40,"maximum":6.71,"gross_charge":140.25,"discounted_cash":140.25,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":4.04,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":3.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":4.82,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":6.71,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6.71,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":3.04,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":3.45,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":2.76,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":3.45,"methodology":"fee schedule"},{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":2.40,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":2.42,"methodology":"fee schedule"}]}]},{"description":"Hydroxyprogesterone, 17-d ","code_information":[{"code":"304","type":"RC"},{"code":"83498","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":44.69,"maximum":105.96,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":44.69,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":104.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":49.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":49.67,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":105.96,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC ","code_information":[{"code":"143","type":"RC"},{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) ","code_information":[{"code":"43260","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve ","code_information":[{"code":"25023","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"SEPTIC ARTHRITIS WITH CC ","code_information":[{"code":"149","type":"RC"},{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include a ","code_information":[{"code":"81414","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":467.92,"maximum":2491.00,"payers_information":[{"payer_name":"Anthem","plan_name":"MCR","standard_charge_dollar":596.60,"methodology":"fee schedule"},{"payer_name":"Centene Granite State Health","plan_name":"HIX","standard_charge_dollar":1022.35,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":2491.00,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":2490.24,"methodology":"fee schedule"},{"payer_name":"Cigna HealthSpring","plan_name":"MGMCR","standard_charge_dollar":596.60,"methodology":"fee schedule"},{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":596.60,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":1896.96,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":2155.62,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":1724.55,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":2155.62,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"PPO","standard_charge_dollar":1652.35,"methodology":"fee schedule"},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"John Hancock","plan_name":"COMM","standard_charge_dollar":467.92,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"MCR","standard_charge_dollar":608.30,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"MCR","standard_charge_dollar":587.82,"methodology":"fee schedule"},{"payer_name":"United Behavioral Health","plan_name":"VACCN","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"United VA CCN","plan_name":"FED","standard_charge_dollar":584.90,"methodology":"fee schedule"},{"payer_name":"Wellsense","plan_name":"MCR","standard_charge_dollar":608.30,"methodology":"fee schedule"}]}]},{"description":"Liver and spleen imaging; static only ","code_information":[{"code":"349","type":"RC"},{"code":"78215","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":937.74,"maximum":1041.73,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":937.74,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1034.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1041.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1041.73,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1034.43,"methodology":"fee schedule"}]}]},{"description":"Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without internal fixation, without bone graft ","code_information":[{"code":"360","type":"RC"},{"code":"61586","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Nephrology (chronic kidney disease), nuclear magnetic resonance spectroscopy measurement of myo-inositol, valine, and creatinine, algorithmically combined with cystatin C and demographic data to deter ","code_information":[{"code":"0259U","type":"CPT"},{"code":"302","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":86.71,"maximum":205.57,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":86.71,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":202.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":96.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":96.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":205.57,"methodology":"fee schedule"}]}]},{"description":"Inj, polatuzumab vedotin 1 ","code_information":[{"code":"09331","type":"APC"}],"standard_charges":[{"setting":"outpatient","minimum":132.57,"maximum":133.93,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":132.57,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":133.93,"methodology":"fee schedule"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC ","code_information":[{"code":"066","type":"MS-DRG"},{"code":"145","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Brain imaging, minimum 4 static views; with vascular flow ","code_information":[{"code":"349","type":"RC"},{"code":"78606","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1541.59,"maximum":1712.54,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1541.59,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1700.55,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1712.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1712.54,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1700.55,"methodology":"fee schedule"}]}]},{"description":"Injection procedure for myelography and/or computed tomography, lumbar ","code_information":[{"code":"62284","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular territory (List separately in addition to code for primary procedure) ","code_information":[{"code":"490","type":"RC"},{"code":"61642","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":5834.00,"maximum":16761.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"}]}]},{"description":"CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC ","code_information":[{"code":"124","type":"RC"},{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":" EKG/ECG (Electrogardiogram) Other  ","code_information":[{"code":"739","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":117.00,"maximum":249.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":117.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":249.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":130.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":130.00,"methodology":"case rate"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":249.00,"methodology":"case rate"}]}]},{"description":"Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views ","code_information":[{"code":"324","type":"RC"},{"code":"71111","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":271.34,"maximum":301.43,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":271.34,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":299.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":301.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":301.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":299.32,"methodology":"fee schedule"}]}]},{"description":"ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC ","code_information":[{"code":"122","type":"MS-DRG"},{"code":"137","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis B virus ","code_information":[{"code":"300","type":"RC"},{"code":"87912","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":423.51,"maximum":1004.05,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":423.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":989.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":470.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1004.05,"methodology":"fee schedule"}]}]},{"description":"Technetium tc-99m tetrofosmin, diagnostic, per study dose ","code_information":[{"code":"A9502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":96.17,"maximum":233.28,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":111.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":127.91,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":123.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"INDEMNITY","standard_charge_dollar":101.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":123.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":152.63,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":233.28,"methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":233.28,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":105.79,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":120.21,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":96.17,"methodology":"fee schedule"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":120.21,"methodology":"fee schedule"}]}]},{"description":"Carcinoembryonic antigen (CEA) ","code_information":[{"code":"301","type":"RC"},{"code":"36908","type":"CDM"},{"code":"82378","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":31.19,"maximum":73.94,"gross_charge":901.50,"discounted_cash":901.50,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":31.19,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":72.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":34.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":34.66,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":73.94,"methodology":"fee schedule"}]}]},{"description":"Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure) ","code_information":[{"code":"369","type":"RC"},{"code":"44015","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Oncology (breast ductal carcinoma in situ), mRNA, gene expression progiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm ","code_information":[{"code":"0045U","type":"CPT"},{"code":"303","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":6371.09,"maximum":15104.70,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":6371.09,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":14887.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7079.84,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":15104.70,"methodology":"fee schedule"}]}]},{"description":"PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH ","code_information":[{"code":"211","type":"RC"},{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision o ","code_information":[{"code":"369","type":"RC"},{"code":"50323","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Osmotic fragility, RBC; incubated ","code_information":[{"code":"301","type":"RC"},{"code":"85557","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":21.98,"maximum":52.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":21.98,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":51.36,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":24.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":24.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":52.10,"methodology":"fee schedule"}]}]},{"description":"Angiography, extremity, bilateral, radiological supervision and interpretation ","code_information":[{"code":"409","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":373.88,"maximum":415.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":373.88,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":412.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":415.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":415.35,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":412.44,"methodology":"fee schedule"}]}]},{"description":"Leukocyte assessment, fecal, qualitative or semiquantitative ","code_information":[{"code":"301","type":"RC"},{"code":"89055","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":7.02,"maximum":16.65,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":7.02,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":7.81,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16.65,"methodology":"fee schedule"}]}]},{"description":"Removal of implanted vestibular device, unilateral ","code_information":[{"code":"0726T","type":"CPT"},{"code":"750","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"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":[{"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":85.43,"maximum":94.90,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":85.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":94.24,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":94.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":94.90,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":94.24,"methodology":"fee schedule"}]}]},{"description":"Impression and custom preparation; surgical obturator prosthesis ","code_information":[{"code":"21076","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":12033.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":12033.90,"methodology":"case rate"}]}]},{"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":4667.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4667.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5186.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8238.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences ","code_information":[{"code":"322","type":"RC"},{"code":"70543","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1783.27,"maximum":1981.03,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1783.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1967.15,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1981.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1981.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1967.15,"methodology":"fee schedule"}]}]},{"description":"SIMPLE PNEUMONIA AND PLEURISY WITH CC ","code_information":[{"code":"143","type":"RC"},{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"COMPLICATED PEPTIC ULCER WITHOUT CC/MCC ","code_information":[{"code":"116","type":"RC"},{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia ","code_information":[{"code":"28635","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":6031.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5003.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":6031.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":2258.56,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":2258.56,"methodology":"case rate"}]}]},{"description":"Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism ","code_information":[{"code":"309","type":"RC"},{"code":"87299","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":26.48,"maximum":62.79,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":26.48,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":61.89,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":29.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":29.43,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":62.79,"methodology":"fee schedule"}]}]},{"description":"Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure) ","code_information":[{"code":"10006","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC ","code_information":[{"code":"074","type":"MS-DRG"},{"code":"167","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"AFTERCARE WITH CC/MCC ","code_information":[{"code":"114","type":"RC"},{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC ","code_information":[{"code":"115","type":"RC"},{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure) ","code_information":[{"code":"58400","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Corticosterone ","code_information":[{"code":"305","type":"RC"},{"code":"82528","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":37.05,"maximum":87.83,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":37.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":86.57,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":41.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":41.17,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":87.83,"methodology":"fee schedule"}]}]},{"description":"Vestibular device implantation, unilateral ","code_information":[{"code":"0725T","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation ","code_information":[{"code":"402","type":"RC"},{"code":"76948","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":253.50,"maximum":281.62,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":253.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":279.64,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":281.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":281.62,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":279.64,"methodology":"fee schedule"}]}]},{"description":"Radical resection of tumor; ischial tuberosity and greater trochanter of femur ","code_information":[{"code":"27078","type":"CPT"},{"code":"481","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":26605.10,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":26605.10,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":26605.10,"methodology":"case rate"}]}]},{"description":"Hydroxyproline; total ","code_information":[{"code":"303","type":"RC"},{"code":"83505","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":39.97,"maximum":94.77,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":39.97,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":93.41,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":44.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":44.42,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":94.77,"methodology":"fee schedule"}]}]},{"description":"ACUTE LEUKEMIA WITH MCC ","code_information":[{"code":"114","type":"RC"},{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Removal of subdeltoid calcareous deposits, open ","code_information":[{"code":"23000","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"PSYCHOSES  IPF","code_information":[{"code":"114","type":"RC"},{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":974.84,"maximum":994.34,"payers_information":[{"payer_name":"Evernorth Behavioral Health","plan_name":"MCR","standard_charge_dollar":994.34,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "},{"payer_name":"Humana","plan_name":"MCR","standard_charge_dollar":974.84,"methodology":"fee schedule","additional_payer_notes":"Days 10+. "}]}]},{"description":"Angiography, pelvic, selective or supraselective, radiological supervision and interpretation ","code_information":[{"code":"409","type":"RC"},{"code":"75736","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":489.07,"maximum":543.31,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":489.07,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":539.50,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":543.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":543.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":539.50,"methodology":"fee schedule"}]}]},{"description":"SEIZURES WITHOUT MCC ","code_information":[{"code":"101","type":"MS-DRG"},{"code":"214","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC ","code_information":[{"code":"064","type":"MS-DRG"},{"code":"156","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"ACUTE LEUKEMIA WITH CC ","code_information":[{"code":"135","type":"RC"},{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) ","code_information":[{"code":"320","type":"RC"},{"code":"72195","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1200.70,"maximum":1333.86,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1200.70,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1324.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1333.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1333.86,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1324.51,"methodology":"fee schedule"}]}]},{"description":"Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral ","code_information":[{"code":"54420","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) ","code_information":[{"code":"324","type":"RC"},{"code":"70540","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1189.65,"maximum":1321.58,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1189.65,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1312.32,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1321.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1321.58,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1312.32,"methodology":"fee schedule"}]}]},{"description":"Capsulotomy, posterior capsular release, knee ","code_information":[{"code":"27435","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Incision and drainage, leg or ankle; infected bursa ","code_information":[{"code":"27604","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":7032.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":5834.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":7032.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":5383.60,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":5383.60,"methodology":"case rate"}]}]},{"description":"Troponin, qualitative ","code_information":[{"code":"300","type":"RC"},{"code":"84512","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":16.60,"maximum":39.35,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":16.60,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":38.79,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":18.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":18.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":39.35,"methodology":"fee schedule"}]}]},{"description":"IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (eg, Southern blot) ","code_information":[{"code":"303","type":"RC"},{"code":"81262","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":112.76,"maximum":267.34,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":112.76,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":263.51,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":125.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":125.31,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":267.34,"methodology":"fee schedule"}]}]},{"description":"Thymol turbidity, blood ","code_information":[{"code":"302","type":"RC"},{"code":"P2033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8.14,"maximum":19.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8.14,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19.03,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9.05,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19.30,"methodology":"fee schedule"}]}]},{"description":"HIV WITH MAJOR RELATED CONDITION WITH MCC ","code_information":[{"code":"112","type":"RC"},{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues ","code_information":[{"code":"361","type":"RC"},{"code":"42810","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Ligation, major artery (eg, post-traumatic, rupture); chest ","code_information":[{"code":"361","type":"RC"},{"code":"37616","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction ","code_information":[{"code":"369","type":"RC"},{"code":"69636","type":"CPT"}],"standard_charges":[{"setting":"outpatient","minimum":4769.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":4769.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":5299.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":8420.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE ","code_information":[{"code":"175","type":"MS-DRG"},{"code":"206","type":"RC"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; with grafting ","code_information":[{"code":"22319","type":"CPT"},{"code":"369","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":3302.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":3302.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":3669.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":5855.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) ","code_information":[{"code":"19364","type":"CPT"},{"code":"761","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":30042.00,"maximum":36212.00,"payers_information":[{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) ","code_information":[{"code":"19364","type":"CPT"},{"code":"490","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"MALIGNANT BREAST DISORDERS WITH MCC* ","code_information":[{"code":"597","type":"TRIS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":14016.47,"maximum":14160.97,"payers_information":[{"payer_name":"Humana Military","plan_name":"TRICR","standard_charge_dollar":14016.47,"methodology":"fee schedule"},{"payer_name":"Martin's Point Health","plan_name":"TRICR","standard_charge_dollar":14160.97,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, upper extremity; without contrast material ","code_information":[{"code":"409","type":"RC"},{"code":"73200","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":610.27,"maximum":677.95,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":610.27,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":673.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":677.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":677.95,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":673.20,"methodology":"fee schedule"}]}]},{"description":"INFLAMMATORY BOWEL DISEASE WITH MCC ","code_information":[{"code":"156","type":"RC"},{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) ","code_information":[{"code":"81306","type":"CPT"},{"code":"925","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":479.29,"maximum":1136.30,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":479.29,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":1119.99,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":532.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":532.61,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":1136.30,"methodology":"fee schedule"}]}]},{"description":"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC ","code_information":[{"code":"131","type":"RC"},{"code":"605","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Thyroidectomy, total or complete with parathyroid autotransplantation ","code_information":[{"code":"369","type":"RC"},{"code":"C7555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","minimum":8512.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8512.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9458.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":16761.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"}]}]},{"description":"Graft for facial nerve paralysis; free muscle flap by microsurgical technique ","code_information":[{"code":"15842","type":"CPT"},{"code":"360","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22929.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":19023.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22929.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":8425.41,"methodology":"case rate"}]}]},{"description":"Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) ","code_information":[{"code":"32507","type":"CPT"},{"code":"499","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":8993.00,"maximum":36212.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":8993.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":9992.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":19041.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":30042.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":36212.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"POS","standard_charge_dollar":11152.90,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"PPO","standard_charge_dollar":11152.90,"methodology":"case rate"}]}]},{"description":"FRACTURES OF FEMUR WITHOUT MCC ","code_information":[{"code":"153","type":"RC"},{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","minimum":3822.00,"maximum":4777.00,"payers_information":[{"payer_name":"Harvard Pilgrim","plan_name":"ELEVATE","standard_charge_dollar":4204.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"HMO","standard_charge_dollar":4777.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"INDIVIDUAL","standard_charge_dollar":3822.00,"methodology":"per diem"},{"payer_name":"Harvard Pilgrim","plan_name":"POS","standard_charge_dollar":4777.00,"methodology":"per diem"}]}]},{"description":"Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first void urine following digital rectal examination, algorithn reporteed a ","code_information":[{"code":"0339U","type":"CPT"},{"code":"304","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1250.20,"maximum":2964.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1250.20,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2921.44,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1389.28,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2964.00,"methodology":"fee schedule"}]}]},{"description":"Computed tomography, head or brain; without contrast material ","code_information":[{"code":"322","type":"RC"},{"code":"70450","type":"CPT"}],"standard_charges":[{"modifiers":"26","modifiers_description":"Professional Component","setting":"outpatient","minimum":202.21,"maximum":224.63,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":202.21,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":223.06,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":224.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":224.63,"methodology":"fee schedule"},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":223.06,"methodology":"fee schedule"}]}]},{"description":"Excision, lesion of tendon sheath, forearm and/or wrist ","code_information":[{"code":"25110","type":"CPT"},{"code":"790","type":"RC"}],"standard_charges":[{"setting":"outpatient","minimum":1540.00,"maximum":22274.00,"payers_information":[{"payer_name":"Anthem","plan_name":"BlueChoice","standard_charge_dollar":1540.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"FEP","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"HMO","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"POS","standard_charge_dollar":1711.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Anthem","plan_name":"PPO","standard_charge_dollar":2868.00,"methodology":"case rate","additional_payer_notes":"The rate (in dollars) may be further adjusted for multiple procedure logic."},{"payer_name":"Cigna","plan_name":"HMO","standard_charge_dollar":18478.00,"methodology":"case rate"},{"payer_name":"Cigna","plan_name":"PPO","standard_charge_dollar":22274.00,"methodology":"case rate"},{"payer_name":"Tufts Health Plan","plan_name":"HMO","standard_charge_dollar":8425.41,"methodology":"case rate"},{"payer_name":"Tufts Health